Although intuitive lowed for situations perceived as diagnostic challenges purchase tadalafil 2.5mg without prescription impotence jelly, judgment may be most appropriate in the uncertain cheap tadalafil 20mg on-line impotence injections medications, fast- there is also evidence that as physicians gain experience and paced field environment where Klein observed his subjects, expertise, most problems are solved by some sort of pattern- other strategies might best suit the laboratory environment recognition process, either by recalling prior similar cases, that others use to study decision making. In addition, forc- attending to prototypical features, or other similar strate- ing research subjects to verbally explain their strategies, as 125–129 130 128 done in most experimental studies of physician problem gies. As Eva and Norman and Klein have em- phasized, most of the time this pattern recognition serves the solving, may lead to the hypothetico-deductive description. However, it is during the times when it does found his subjects had a very difficult time articulating their not work, whether because of lack of knowledge or because strategies. A striking example derives from surveys of real world, either in content or in difficulty. As an example, academic professionals, 94% of whom rate themselves in 134 to study diagnostic problem solving, most researchers of the top half of their profession. Similarly, only 1% of 139 135 necessity use “diagnostically challenging cases,” which drivers rate their skills below that of the average driver. However, in experimental studies of know or do not know something) is found in many areas and clinician diagnostic decision making, the reverse is true. The challenges of studying clinicians’ diagnostic accuracy Most of the research that has examined expert decision in the natural environment are compounded by the fact that making in natural environments, however, has concluded most initial diagnoses are made in ambulatory settings, that rapid and accurate pattern recognition is characteristic 82 which are notoriously difficult to assess. Klein, Gladwell, and others have examined how experts in fields other than medicine diagnose a situa- Complacency Aspect of Overconfidence tion and find that they routinely rapidly and accurately Complacency (i. Klein refers to this process as “recognition primed” error, and the belief that errors are inevitable. Complacency decision making, referring to the extensive experience of the may show up as thinking that misdiagnoses are more infre- expert with previous similar cases. Gigerenzer and Gold- quent than they actually are, that the problem exists but not 136 stein similarly support the concept that most real-world in the physician’s own practice, that other problems are decisions are made using automatic skills, with “fast and more important to address, or that nothing can be done to frugal” heuristics that lead to the correct decisions with minimize diagnostic errors. Given the overwhelming evidence that diagnostic error Again, when experts recognize that the pattern is incor- exists at nontrivial rates, one might assume that physicians rect they may revert back to a hypothesis testing mode or would appreciate that such error is a serious problem. In 1 study, family physicians asked to 140 tise is characterized by the ability to recognize when one’s recall memorable errors were able to recall very few. The denomina- When giving talks to groups of physicians on diagnostic tor that the clinician uses is clearly not the number of errors, Dr. Graber (coauthor of this article) frequently asks adverse events, which some studies of diagnostic errors whether they have made a diagnostic error in the past year. Nor is it a selected sample of challenging cases, Typically, only 1% admit to having made a diagnostic error. Because most visits are not diagnosti- The concept that they, personally, could err at a significant cally challenging, the physician not only is going to diag- rate is inconceivable to most physicians. Indeed, 93% of physicians in formal ticular complaint because they are cured or treated appro- surveys reported that they practice “defensive medicine,” priately. The cost of defensive medicine is estimated to consume 5% to 9% of healthcare expenditures returning when symptoms are more pronounced and thus 142 eventually getting diagnosed correctly. We conclude that physicians ac- knowledge the possibility of error, but believe that mistakes feedback is not even expected, feedback that is delayed or are made by others. That is, in the absence of information that the lence of error and physician perception of their own error diagnosis is wrong, it is assumed to be correct (“no news is rate has not been formally quantified and is only indirectly good news”). This phenomenom is illustrated in epigraph discussed in the medical literature, but lies at the crux of the above from Herold, “Doctors think a lot of patients are diagnostic error puzzle, and explains in part why so little 85 cured who have simply quit in disgust. Physicians tend that misdiagnosis is not a major problem, while not neces- to be overconfident of their diagnoses and are largely un- sarily correct, may indeed reflect arrogance, “tall in the aware of this tendency at any conscious level. From the physician’s per- Thus, despite the evidence that misdiagnoses do occur spective, such self-deception can have positive effects. For more frequently than often presumed by clinicians, and example, it can help foster the patient’s perception of the despite the fact that recognizing that they do occur is the physician as an all-knowing healer, thus promoting trust, first step to correcting the problem, the assumption that adherence to the physician’s advice, and an effective pa- misdiagnoses are made only a very small percentage of the tient-physician relationship. The selective outcome data are available for physicians to accu- authors cite several studies that examined the outcomes of rately calibrate the extent of their own misdiagnoses. In many cases, the overrides were considered clinically Summary justified, and when they were not, there were very few Pulling together the research described above, we can see ( 3%) adverse events as a result. While it may be argued why there may be complacency and why it is difficult to that even those few adverse events could have been averted, address. First, physicians generate hypotheses almost im- such contentions may not be convincing to a clinician who mediately upon hearing a patient’s initial symptom presen- can point to adverse events that occur even with adherence tation and in many cases these hypotheses suggest a familiar to guidelines or alerts. Second, even if more exploration is needed, the appear to be unavoidable and thus reinforce the physician’s most likely information sought is that which confirms the complacency.

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