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Keywords:

  • clinical reasoning;
  • cognitive biases;
  • cognitive maps;
  • diagnostic error;
  • heuristics;
  • medical decision making

Abstract

Rationale  Diagnostic reasoning is a critical aspect of clinical performance, having a high impact on quality and safety of care. Although diagnosis is fundamental in medicine, we still have a poor understanding of the factors that determine its course.

According to traditional understanding, all information used in diagnostic reasoning is objective and logically driven. However, these conditions are not always met. Although we would be less likely to make an inaccurate diagnosis when following rational decision making, as described by normative models, the real diagnostic process works in a different way. Recent work has described the major cognitive biases in medicine as well as a number of strategies for reducing them, collectively called debiasing techniques. However, advances have encountered obstacles in achieving implementation into clinical practice.

Aims and objectives  While traditional understanding of clinical reasoning has failed to consider contextual factors, most debiasing techniques seem to fail in raising sound and safer medical praxis. Technological solutions, being data driven, are fundamental in increasing care safety, but they need to consider human factors. Thus, balanced models, cognitive driven and technology based, are needed in day-to-day applications to actually improve the diagnostic process. The purpose of this article, then, is to provide insight into cognitive influences that have resulted in wrong, delayed or missed diagnosis.

Conclusions  Using a cognitive approach, we describe the basis of medical error, with particular emphasis on diagnostic error. We then propose a conceptual scheme of the diagnostic process by the use of fuzzy cognitive maps.