Medical Education
Wednesday, March 28, 2007
Another piece in the New England Journal of Medicine that I found of interest was a series of letters about medical education. I feel strongly that it is time to integrate cognitive psychology into the curriculum. Physicians are making decisions all the time under conditions of uncertainty, with limited data. The human mind is wired to take shortcuts, and our biases and emotions can strongly color our reasoning. Scant attention is paid to this critical cognitive dimension which underlies misdiagnosis. Over the past years, many medical educators have proposed algorithms and illness scripts to medical students and residents. These are based on prototypes, typical patients with diseases that have typical symptoms and findings on physical examination or laboratory testing. As the letters in the New England Journal of Medicine articulate, such illness scripts and algorithms are very seductive, because, working under time pressure, and with incomplete data, it is much easier to follow than to lead, much easier to just grab on to the algorithm or illness script rather than take the time to think expansively. This is not to say that such algorithms are worthless. But they have to be put into context, consulted and evaluated, but not automatically adopted. As several of the medical educators write in the New England Journal of Medicine, illness scripts can paradoxically foster misdiagnosis by causing anchoring errors and premature closure.I am heartened by the increased debate around these issues. Every misdiagnosis I made was painful – most painful, of course, for the patient, but, also for me. As physicians, we are constantly trying to do our best. We know that we are imperfect, and will always fall short of one-hundred-percent. So, we need to work in an environment that allows us to think better, and we need to be educated in self-awareness, both about our cognitive processes and how our emotional state can affect our judgment. For those interested in delving more deeply, I suggest reading the Ginsburg and Berenson article as well as the letters section of the March 22, 2007, New England Journal of Medicine.
