Intended for healthcare professionals

Rapid response to:

Practice A Patient’s Journey

Sir Karl Popper, swans, and the general practitioner

BMJ 2011; 343 doi: (Published 03 October 2011) Cite this as: BMJ 2011;343:d5469

Rapid Response:

Making the right diagnosis - Critical thinking skills needed

The author's initial journey as a patient is highly regrettable.(1) He is certainly right to point out 'confirmation bias' as an important error in medical decision making. But there are two issues that need separating: getting the medical assessment right and then, based on the facts available, the process of clinical decision making.

Mr Berghmans' general practitioner did not follow the 'ground rules' of how a patient's assessment should be carried out, as pointed out by previous respondents (e.g. patient not examined, Red Flags ignored). This makes it much more likely to come to the wrong diagnosis and get subsequent decisions, regarding the investigations and management needed, wrong as well.

But even without breaking those 'ground rules' doctors can make the wrong decisions. As Vincent Charles points out in his book 'Patient Safety' : "Doctors and nurses and other health care staff receive almost no training in decision making" and "a distinction has to be made between the content of decision making and the best to make decisions ".(2) In my experience this is certainly true for the generation of doctors I trained with.

What is needed for good decision-making in medicine? Certainly some of the following: 1) Information = facts (these can be elucidated by concise but complete medical history and physical examination), 2) time, 3) alertness, 4) critical thinking skills. In bad decision making the following thought processes have been known to be dominant: 1) group think, 2) confirmation bias, 3) preconception/first impression bias (=relying on intuition) and other factors, that can be found in the very noteworthy chapter 'Critical thinking and reasoning in Emergency Medicine' of the book 'Patient Safety in Emergency Medicine' by Croskerry et al.(3)

Mr Berghmans writes "Doctor's and in particular GPs, should always bear in mind the fallibility of their assumptions". This is the point I am trying to make: good clinical decision making should not be based on assumptions, but as much as possible on facts. An important critical thinking skill is being able to pause and consider the question: Do I assume here, or is this a fact, on which I base my decision/diagnosis?

References 1. Berghmans R, Schouten HC. Sir Karl Popper, swans and the general practitioner. BMJ 2011;343:d5469.

2. Vincent Charles. Patient Safety. Oxford: BMJ Books, Wiley- Blackwell 2010, 2nd edition.

3. Croskerry P, Cosby KS, Schenkel SM, Wears R. Patient Safety in Emergency Medicine. Philadelphia: Lippincott Williams&Wilkins 2009.

Competing interests: None declared

Competing interests: No competing interests

06 November 2011