More on the Causes of Errors in Clinical Reasoning

To the Editor: The Perspective by Norman and colleagues1 is at odds with the literature on rationality in decision making. Efforts to devalue cognitive bias by claiming the effects have only been demonstrated in undergraduates should be put to rest. Leading cognitive scientists describe such claims as “nonsense,”2 and Kahneman himself dismissed the notion as “cartoonish.”3 Widespread deviations from normative decision making, experimentally demonstrated over the last 40 years, have been replicated many times over in representative populations.2 Cognitive biases are real, abundant, and a major problem in clinical decision making. To deny their existence is irrational. Early in the article a straw man is erected by attributing clinical reasoning errors to either a lack of medical knowledge or to cognitive bias. Several studies have found cognitive failings are more likely due to how physicians think rather than what they know, and most clinicians confirm this is what happens in practice. Throughout the article, findings from a variety of studies are interpreted in a biased fashion. Demonstrations of the impact of cognitive bias on medical decision making are minimized or ignored. Major reviews are omitted, and there is a puzzling acquiescence by coauthors to discount their own published demonstrations of cognitive biases. The potential of cognitive bias mitigation (CBM) strategies is also minimized, and erroneous statements are made. An article of mine is cited to support their statement that “evidence is consistent in demonstrating that such strategies have no or limited effectiveness.”1 In fact, I was saying the opposite. In contrast to the view presented in this Perspective,1 a recent systematic review of 28 studies in CBM and dual process thinking led the authors to conclude, “Results to date are promising and this relatively young field is now close to a point where these kinds of cognitive interventions can be recommended to educators.”4 To delay this important initiative to reduce diagnostic failure would be unconscionable and unethical. Pat Croskerry, MD, PhDProfessor, Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; [email protected]

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