Skip to main content

Main menu

  • Home
  • Content
    • Current Issue
    • Ahead of Print
    • Past Issues
    • Supplements
    • Article Type
  • Specialty
    • Articles by Specialty
  • CME/MOC
    • Articles
    • Calendar
  • Info For
    • Manuscript Submission
    • Authors & Reviewers
    • Subscriptions
    • About CCJM
    • Contact Us
    • Media Kit
  • Conversations with Leaders
  • Conference Coverage
    • Kidney Week 2024
    • CHEST 2024
    • ACR Convergence 2023
    • Kidney Week 2023
    • ObesityWeek 2023
    • IDWeek 2023
    • CHEST 2023
    • MDS 2023
    • IAS 2023
    • ACP 2023
    • AAN 2023
    • ACC / WCC 2023
    • AAAAI Meeting 2023
    • ACR Convergence 2022
    • Kidney Week 2022
    • AIDS 2022
  • Other Publications
    • www.clevelandclinic.org

User menu

  • Register
  • Log in

Search

  • Advanced search
Cleveland Clinic Journal of Medicine
  • Other Publications
    • www.clevelandclinic.org
  • Register
  • Log in
Cleveland Clinic Journal of Medicine

Advanced Search

  • Home
  • Content
    • Current Issue
    • Ahead of Print
    • Past Issues
    • Supplements
    • Article Type
  • Specialty
    • Articles by Specialty
  • CME/MOC
    • Articles
    • Calendar
  • Info For
    • Manuscript Submission
    • Authors & Reviewers
    • Subscriptions
    • About CCJM
    • Contact Us
    • Media Kit
  • Conversations with Leaders
  • Conference Coverage
    • Kidney Week 2024
    • CHEST 2024
    • ACR Convergence 2023
    • Kidney Week 2023
    • ObesityWeek 2023
    • IDWeek 2023
    • CHEST 2023
    • MDS 2023
    • IAS 2023
    • ACP 2023
    • AAN 2023
    • ACC / WCC 2023
    • AAAAI Meeting 2023
    • ACR Convergence 2022
    • Kidney Week 2022
    • AIDS 2022
Departments

In reply: Cognitive bias and diagnostic error (November 2015)

Nikhil Mull, MD, James B. Reilly, MD, MS and Jennifer S. Myers, MD
Cleveland Clinic Journal of Medicine June 2016, 83 (6) 408; DOI: https://doi.org/10.3949/ccjm.83c.06004
Nikhil Mull
University of Pennsylvania, Philadelphia
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
James B. Reilly
Temple University, Pittsburgh, PA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Jennifer S. Myers
University of Pennsylvania, Philadelphia
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Info & Metrics
  • PDF
Loading

IN REPLY: We thank Dr. Field for his insights and personal observations related to diagnosis and biases that contribute to diagnostic errors.

Dr. Field’s comment about the importance of revisiting one’s initial working diagnosis is consistent with our proposed diagnostic time out. A diagnostic time out can incorporate a short checklist and aid in debiasing clinicians when findings do not fit the case presentation, such as lack of response to diuretic therapy. Being mindful of slowing down and not necessarily rushing to judgment is another important component.1 Of note, the residents in our case did revisit their initial working diagnosis, as suggested by Dr. Field. Questions from learners have great potential to serve as debiasing instruments and should always be encouraged. Those who do not work with students can do the same by speaking with nurses or other members of the healthcare team, who offer observations that busy physicians might miss.

Our case highlights the problem that we lack objective criteria to diagnose symptomatic heart failure. While B-type natriuretic factor (BNP) has a strong negative predictive value, serial BNP measurements have not been established to be helpful in the management of heart failure.2 Although certain findings on chest radiography have strong positive and negative likelihood associations, the role of serial chest radiographs is less clear.3 Thus, heart failure remains a clinical diagnosis in current practice.

As Dr. Field points out, the accuracy and performance characteristics of diagnostic testing, such as the respiratory rate, need to be considered in conjunction with debiasing strategies to achieve higher diagnostic accuracy. Multiple factors can contribute to low-performing or misinterpreted diagnostic tests, and inaccurate vital signs have been shown to be similarly prone to potential error.4

Finally, we wholeheartedly agree with Dr. Field’s comment on unnecessary testing. High-value care is appropriate care. Using Bayesian reasoning to guide testing, monitoring the treatment course appropriately, and eliminating waste is highly likely to improve both value and diagnostic accuracy. Automated, ritual ordering of daily tests can indicate that thinking has been shut off, leaving clinicians susceptible to premature closure of the diagnostic process as well as the potential for “incidentalomas” to distract them from the right diagnosis, all the while leading to low-value care such as wasteful spending, patient dissatisfaction, and hospital-acquired anemia.5 We believe that deciding on a daily basis what the next day’s tests will be can be another powerful debiasing habit, one with benefits beyond diagnosis.

  • Copyright © 2016 The Cleveland Clinic Foundation. All Rights Reserved.

REFERENCES

  1. ↵
    1. Schiff GD
    . Minimizing diagnostic error: the importance of follow-up and feedback. Am J Med 2008; 121(suppl): S38–S42.
    OpenUrlPubMed
  2. ↵
    1. Yancy CW,
    2. Jessup M,
    3. Bozkurt B,
    4. et al
    . 2013 ACCF/AHA guideline for the management of heart failure. Circulation 2013; 128: e240–e327.
    OpenUrlFREE Full Text
  3. ↵
    1. Wang CS,
    2. FitzGerald JM,
    3. Schulzer M,
    4. Mak E,
    5. Ayas NT
    . Does this dyspneic patient in the emergency department have congestive heart failure? JAMA 2005; 294:1944–1956.
    OpenUrlCrossRefPubMed
  4. ↵
    1. Philip KE,
    2. Pack E,
    3. Cambiano V,
    4. Rollmann H,
    5. Weil S,
    6. O’Beirne J
    . The accuracy of respiratory rate assessment by doctors in a London teaching hospital: a cross-sectional study. J Clin Monit Comput 2015; 29:455–460.
    OpenUrl
  5. ↵
    1. Koch CG,
    2. Li L,
    3. Sun Z,
    4. et al
    . Hospital-acquired anemia: prevalence, outcomes, and healthcare implications. J Hosp Med 2013; 8:506–512.
    OpenUrlCrossRefPubMed
PreviousNext
Back to top

In this issue

Cleveland Clinic Journal of Medicine: 83 (6)
Cleveland Clinic Journal of Medicine
Vol. 83, Issue 6
1 Jun 2016
  • Table of Contents
  • Table of Contents (PDF)
  • Index by author
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on Cleveland Clinic Journal of Medicine.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
In reply: Cognitive bias and diagnostic error (November 2015)
(Your Name) has sent you a message from Cleveland Clinic Journal of Medicine
(Your Name) thought you would like to see the Cleveland Clinic Journal of Medicine web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
In reply: Cognitive bias and diagnostic error (November 2015)
Nikhil Mull, James B. Reilly, Jennifer S. Myers
Cleveland Clinic Journal of Medicine Jun 2016, 83 (6) 408; DOI: 10.3949/ccjm.83c.06004

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
In reply: Cognitive bias and diagnostic error (November 2015)
Nikhil Mull, James B. Reilly, Jennifer S. Myers
Cleveland Clinic Journal of Medicine Jun 2016, 83 (6) 408; DOI: 10.3949/ccjm.83c.06004
Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Linkedin Share Button

Jump to section

  • Article
    • REFERENCES
  • Info & Metrics
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

Departments

  • When should we consider SGLT-2 inhibitors in patients with acute decompensated heart failure?
  • Our Peer-Reviewers for 2023
  • Our Peer-Reviewers For 2022
Show more Departments

Letters to the editor

  • In Reply: In defense of the anion gap
  • In defense of the anion gap
  • In Reply: Insomnia in older adults
Show more Letters to the editor

Similar Articles

Subjects

  • Cardiology
  • Emergency Medicine
  • Hospital Medicine

Navigate

  • Current Issue
  • Past Issues
  • Supplements
  • Article Type
  • Specialty
  • CME/MOC Articles
  • CME/MOC Calendar
  • Media Kit

Authors & Reviewers

  • Manuscript Submission
  • Authors & Reviewers
  • Subscriptions
  • About CCJM
  • Contact Us
  • Cleveland Clinic Center for Continuing Education
  • Consult QD

Share your suggestions!

Copyright © 2025 The Cleveland Clinic Foundation. All rights reserved. The information provided is for educational purposes only. Use of this website is subject to the website terms of use and privacy policy. 

Powered by HighWire