The role of patient involvement in the diagnostic process in internal medicine: A cognitive approach

Abstract

Much cognitive and clinical research has addressed clinical reasoning, pointing out that physicians often have difficulties in following a linear course when making accurate diagnoses. Some authors suspect that physicians make mistakes because they unknowingly fail to observe the laws of formal logic and that their reasoning becomes influenced by contextual factors. In this paper, we introduce some basic principles of the cognitive approach to medical decision making and we describe the cognitive balanced model. Then we discuss the relationship between construction of mental models, cognitive biases and patient involvement by the use of a clinical vignette. Medical decisions may be considered fundamentally biased since the use of judgment heuristics and a combination of cognitive-related and system-related factors limit physicians' rationality. While traditional understanding of clinical reasoning has failed to consider contextual factors, most techniques designed to avoid biases seem to fail in promoting sound and safer medical practice. In particular, we argue that an unbiased process requires the use of a cognitive balanced model, in which analytical and intuitive mind skills should be properly integrated. In order to improve medical decision making and thereby lessen incidence of adverse events, it is fundamental to include the patient perspective in a balanced model. Physicians and patients should improve their collective intelligence by sharing mental models within a framework of distributed intelligence.

Full text

The role of patient involvement in the diagnostic process in
Internal Medicine: a cognitive approach
Claudio Lucchiari, Gabriella Pravettoni
Università degli Studi di Milano
This is a pre-print versione. To Cite this article:
LUCCHIARI, Claudio; PRAVETTONI, Gabriella. The role of
patient involvement in the diagnostic process in internal
medicine: a cognitive approach. European journal of internal
medicine, 2013, 24.5: 411-415.
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Abstract
Much cognitive and clinical research has addressed clinical
reasoning, pointing out that physicians often have difficulties in
following a linear course when making accurate diagnoses.
Some authors suspect that physicians make mistakes because
they unknowingly fail to observe the laws of formal logic and
that their reasoning becomes influenced by contextual factors.
In this paper, we introduce some basic principles of the
cognitive approach to medical decision making and we describe
the cognitive balanced model. Then we discuss the relationship
between construction of mental models, cognitive biases and
patient involvement by the use of a clinical vignette.
Medical decisions may be considered fundamentally biased
since the use of judgment heuristics and a combination of
cognitive-related and system-related factors limit physicians'
rationality.
While traditional understanding of clinical reasoning has failed
to consider contextual factors, most techniques designed to
avoid biases seem to fail in promoting sound and safer medical
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practice. In particular, we argue that an unbiased process
requires the use of a cognitive balanced model, in which
analytical and intuitive mind skills should be properly
integrated.
In order to improve medical decision making and thereby
lessen incidence of adverse events, it is fundamental to include
the patient perspective in a balanced model. Physicians and
patients should improve their collective intelligence by sharing
mental models within a framework of distributed intelligence.
Keywords: medical decision making; cognitive biases;
overconfidence; diagnostic errors;
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Introduction
The diagnostic process is probably the most relevant
component in medical decision making from a cognitive point
of view. In fact, physicians need to work like an information
processor, which collects data from the environment, infers
judgments and produces clinical scenarios. Much research has
been devoted to this important topic but most is superficial,
both when it succeeds and when it fails. Actually, diagnostic
error accounts for a substantial portion of all medical errors,
receiving increased attention in the last 30 years [1]. However,
it is astonishing that the error rate seems to remain constant
over time and space, as demonstrated in two studies (one in the
US and one in Germany) which indicate how the error rate has
not substantially changed over since 1980, remaining firmly
anchored in both countries at a rate of around 10%, although
alarmingly a recent systematic review reported a rate as high
as 24% [2].
Generally speaking, most errors are reported to occur
within the information analysis stage. Physicians declare
failures or delays in identifying significant clues and in
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prioritizing clinical information. In this stage, physicians, as
any other expert decision makers, need to gather data from the
environment and to organize them onto a so called mental
model. Indeed, the human mind works on well-structured data
that may be represented and cognitively processed, in order to
define a problem, highlights solutions and takes actions in a
cognitive loop (see figure 1). Thus, all the incoming
information needs to be weighted for relevance and tested for
reliability before being integrated in a mental model [3].
The activation of a first mental model starts with the
diagnostic process. In fact, using this mental structure based on
schemes stored in the long-term memory, a physician may
evaluate the consequences of each possible choice (diagnostic
or therapeutic interventions), in order to plan future actions,
choose scenarios, or even review the active mental model.
Figure 1 here
A number of studies have highlighted the complex nature of
making medical decisions, which cannot be considered a
cognitive exercise completely based on rational and technical
skills [4;5]. In particular, cognitive research has shown that the
clinical setting is influenced by heuristic processes, intuition
and a number of biases, or cognitive illusions, that can lead a
physician far from ideal clinical reasoning [6]. Recent studies
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showed that it is possible to understand and prevent errors in
internal medicine starting by the recognition of the interaction
between cognitive-related and system-related causes [7] and
learning to detect early warnings [8].
A Cognitive Balanced Model
In previous work [9], we have defined a cognitive balanced
model to describe how the clinical decision setting should be
represented by a functional balance between analysis and
intuition, that is, between the two basic components of the
human mind [10]. The cognitive balanced model is based on
the assumption that the use of concepts and logical reasoning
should be developed in medical education along with specific
training within the realm of intuitive skills. In particular, it
emphasizes the importance of developing specific awareness
about of the need for balance, since the lack of awareness will
inevitably expose physicians and patients to clinical hazards.
Indeed, an overconfidence in analytical skills or the
underestimation of the importance of implicit thought will
increase the likelihood of falling into cognitive traps [11], and
failure to understand the origin of many errors.
Of course, the development of analytical skills and intuition
follow different paths. To follow logical and analytical schemas
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it is necessary to learn general methods, specific concepts and
techniques as well as how to apply them in certain domains.
Intuition, in contrast, is developed with experience, essentially
during everyday activity and thus it is difficult to plan
training specifically aimed at develop intuitive skills. However,
it is possible to design education programs compatible with the
needs of the intuitive mind. Generally speaking, a strong
learning environment [12], characterized by consistency,
regularity, timely feedback and meta-cognitive moments can be
considered to be “pro-intuitive” [13].
Medical practitioners must learn to trust their intuition, but
also to know its limits. In particular, intuition is much more
powerful and reliable, when functioning within the specific
context in which it was developed. Doctors’ expert eye should
not be transferred automatically from one medical context to
another.
The cognitive balanced model highlights how these meta-skills
should belong to the cognitive background of a doctor. Without
this background, error prevention protocols and techniques to
cut down biases will always be partial solutions [14]. The
cognitive balanced model also implies that doctors should be
properly supported in both their training, and in their clinical
everyday practice by specific decision aids. However, also
these support systems should be designed to balance the
strength of analytical methods with the need for intuitive
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evaluation. In contrast, most existing support systems have a
cognitive architecture mainly based on analytical algorithms
and static knowledge structures such as decision trees and
deterministic decision-making methods.
Furthermore, our perspective proposes use of general processes
that can be analyzed as a whole, instead of addressing simple
and elementary “mind bugs”. In particular, while agreeing with
the literature data [15] we argue that there are two general
conditions that often lead to an unbalanced decision-making
process and to potential adverse events: overconfidence bias
and premature closure.
Premature closure is the tendency to avoid considering other
possibilities after reaching a diagnosis, while overconfidence
bias is the tendency to overestimate one’s judgment ability.
Premature closure can lead to stopping the diagnostic process
even before a favoured diagnosis is actually confirmed by
appropriate clinical examination. It should derive from a strong
cognitive load which depends on several factors [personal,
inter-personal and contextual) and is time-dependent. More
specifically, premature closure may be the result of the
combination of an individual’s need for cognitive closure along
with certain contextual factors. It is obvious that intuitive
thinking is strongly associated with premature closure, even if
specific training could teach physician both to trust in their
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intuition and to activate subsequent meta-cognitive control on
it.
Also overconfidence is a consequence of a number of direct
and indirect drivers, including age and experience. In
particular, overconfidence bias seems to be particularly
significant for expert doctors, since they have developed sound
competences and confidence in them.
Interestingly, experienced physicians are as likely as novices to
exhibit premature closure and indeed senior physicians may be
particularly predisposed both to premature closure and
overconfidence, probably because of the development of age-
related cognitive constraints [16].
The special importance that overconfidence and premature
closure seem to play in the diagnostic process probably lies in
some basic mind processes. The overconfidence bias leads to
the creation of a conservative mental model, ready to use, and
the need for closure exerts pressure to confirm the same mental
model in order to avoid cognitive and emotional overloading. A
particular mental model, by itself, can also contain complex
analytical processes and procedures, incorporating both
intuitive and analytical knowledge. Nevertheless, a lack of
awareness about decision making mechanisms may lead to the
use of unbalanced models.
In order to avoid the cognitive pitfalls it would be desirable to
implement an unbiased process in which incoming data are
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organized in a mental model that highlights essential
information and leads to a safer diagnostic process.
However, we propose that a balanced process cannot really be
effective within a clinical context if it is built in isolation from
the context. The medical scenario includes different actors, in
particular physicians and patients. To avoid errors and to
strengthen the power of cognitive processes, mental structures
should be shared and the related intelligence distributed.
Patient involvement and error prevention
Although progress has been made in a number of specific areas
of prevention of errors, the patient's role in protecting and
promoting his or her own safety has long been neglected.
The scientific literature on this topic is scarce, despite some
positive cognitive studies which have suggested that this may
be a fruitful area to cut down errors. Indeed it has been
observed that patients seem to be quite efficient in detecting
errors and reporting risk situations.
Patient involvement in error detection and prevention has been
recommended, for example, by the US Institute of Medicine,
the American Hospital Association and by some clinical
experts [17;18;19]. In particular, the involvement of patients is
thought to be vital in avoiding errors in administration of
drugs, which cause many adverse events. Different studies in
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internal medicine departments showed that prescription-related
error are not rare and that in the last decades error rate did not
substantially change. In particular, errors are originated by
incomplete, duplicative, or contradictory orders or by the
failure to adjust dosages for comorbid conditions.
For instance, in a two-year prospective study on nurses [20],
141 drug administration errors were found on 4.752
hospitalizations. Forty one percent of these errors were errors
in planning (omission of the administration and measurement
checks), 21% were errors in writing or transcription of
prescriptions and 38% were errors in dispensing drugs (mainly
wrong dose or wrong medication). Most researchers suggest to
adopt corrective measures by the implementation of a
computerized physician order entry system that allow the
elimination of transcribing errors and permit the introduction of
alarm systems. However, we argue that an active patient
involvement is equally important.
Administration of medication in cancer patients is particularly
critical, given the narrow therapeutic window of cytotoxic
drugs. Patients undergoing cycles of chemotherapy may be able
to participate in error prevention, since being exposed to
similar procedures several times may enable them to adopt
clinical abilities.
These skills might be considered the result of the development
of clinical competences (knowledge of the therapy,
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pharmacodynamic principles, methods and procedures)
acquired by undergoing continuous clinical testing, inspections
and treatments. The repeated experiences over time, allow the
acquirement of a set of adaptive strategies for patients to take
control of their therapeutic journey [21;22]. If properly
informed and motivated, patients have the capability to play an
important role in the prevention or at least diminution of
adverse events. Yet little research has been undertaken on how
to effectively engage patients in this role of "watchful partner"
in their own healthcare [23;24].
In one study [25] doctors were asked to assess the perceived
effectiveness of fourteen recommended actions to prevent
errors. Results indicated that most actions were considered
effective. However, respondents also indicated that the
possibility to be involved in similar actions in their daily
activity were improbable. Having a greater self-efficacy of
being able to prevent medical errors is significantly correlated
with a higher probability to report and to be engaged in
preventive actions. For instance, feeling able to involve
patients in medical decision making and adverse event
prevention will increase the probability that a physician will
actually work to involve each subsequent patient in their
medical journey. To improve patients’ involvement, thus,
physicians need specific training to increase self-efficacy and
not just a general set of guidelines.
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Clearly, the desire for involvement and participation in the
healthcare process and shared medical decision making also
depends on certain characteristics of patients. Age, gender,
level of education and personality traits are all factors capable
of modulating the need for involvement and the ability to be a
pro-active patient. Generally speaking, younger patients tend to
report a greater desire for involvement than older patients.
Women seem to prefer a more active role than males, as do
patients with more time in higher education. Younger and more
educated patients have a greater ability to obtain and
understand health-related information and thus they will be
more likely to become involved in health-related decisions
[26].
Past experience and the specific disease characteristics are
other components to be considered in understanding a patient’s
ability to be involved [26]. For instance, patients who have had
a recent myocardial infarction, coronary angioplasty or bypass
surgery are more prone to seek involvement in medical
decisions, compared to those patients who have no history of
cardiovascular disease.
The relationship between patient involvement and
cognitive traps: an example.
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Patients can be critical to the efficiency of the diagnostic
process, as illustrated with the following example.
Mr. Smith went to the emergency department with a severe
abdominal pain. The pain arose suddenly, starting from the
solar plexus and spread though to his back, persisting for
several hours, before the decision to go to the nearest hospital.
Here, after a brief giving a complete history including careful
description of his pain, he had an electrocardiogram and blood
tests to rule out a myocardial infarction. This having been
ruled out by normal tests, he was given analgesic drugs and a
proton pump inhibitor, and discharged to the care of his
family doctor.
After a second acute episode, the family doctor referred Mr
Smith to have an esophagogastroduodenoscopy. The
endoscopic examination did not indicate the presence of
gastroesophageal reflux and also the histological results of
biopsies were negative. A diagnosis of moderate chronic
gastritis was made and he was recommended to continue with
the same therapy plus small fonts of Butylscopolamine as
required. The patient continued to suffer painful episodes
which became increasingly difficult to control with his
prescribed drugs so Mr. Smith decided to consult a specialist
in gastroenterology. After a brief history and description of
symptoms, the specialist read the report of the previous
endoscopy and then, having briefly examined the patient
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confirmed the diagnosis of chronic gastritis, agreed with the
existing medications and suggested some diet changes.
Despite good general health, Mr Smith continued to experience
episodes of acute pain, only partially controlled by
Butylscopolamine and began to lose weight, put down to the
results of the dietary restrictions and physical exercise.
Eventually, after four referrals to the emergency department in
eighteen months for acute pain, each time being recommended
the same painkiller and sedative treatments, and the refusal of
further investigation he was seen by a surgeon who suspected
that the pain might be due to biliary colic. A careful ultrasound
confirmed the existence of gallstones and after hospitalisation
he was found to have signs of hepatitis and pancreatitis. The
patient was subsequently operated for removal of his gall
bladder and stones, and discharged from hospital free of pain
for the first time in two years.
The case of Mr. Smith, is not uncommon and has various
interesting facets, most critically the total absence of
involvement of the patient in the diagnostic process. Mr. Smith
was considered by the many doctors who met him (his family
doctor, specialists, emergency department internists) as a mere
symptoms and signs carrier. It is obvious that after the first
diagnosis the mental model of the subsequent doctors was built
instantly on it (so-called anchoring process) [27].
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Indeed, the first question when encountering a patient coming
to the emergency department with a painful condition is often
“did you already suffered from stomach problems?”. A positive
response ("I have been diagnosed with gastritis") will
automatically elicit the activation of a mental model that will
guide the subsequent actions.
Once the pain goes away, the patient does not bring any more
information and thus may be discharged, in order to rapidly
close the case (in fact, the emergency department internist
won’t see the patient anymore). The patient will not be asked
for further information about his state of health (for example,
with respect to weight loss), nor will his request for further
investigation be heeded.
In practice, the use of a stand-alone mental scheme, not to be
shared with the patient, caused an overconfidence bias and
subsequently the need for a premature closure determined the
course, and the end of clinical reasoning among Mr Smith’s
caring professionals.
The last surgeon observed the patient without the filter of the
initial framing information, since his clinical history was
collected anew from the patient, independent of the previous fat
file of case note. In this way, the surgeon was guided only by
his cultural background and expertise that led him to build a
mental model specifically focused on the symptoms which he
ascribed to colic. We argue that greater patient involvement in
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medical decision-making would have allowed internists to
doubt their own mental model and share with the patient a
more flexible one. In this way, Mr. Smith would not have
suffered a two years delay in diagnosis.
Of course, this case could be construed as a classic case of
delayed diagnosis due to a biased mind process, however, it is
our opinion that it is essential to consider also the patient
involvement issues to improve our ability to appraise the whole
situation. In fact, the overconfidence bias and the premature
closure acted not only on the individual doctor, preventing a
balanced logical thought process, but also on the relationship
with others, in this case with the patient.
Lacking technical expertise and specific knowledge the patient
was overwhelmed by each physician’s confidence in their
decisions. Subsequently premature closure precluded the use
of, or the search for further data, such as marginal signs and
perpetuation of the patient’s complaints despite what should
have been appropriate medication.
A doctor/patient relationship model based on openness and
sharing would have allowed the patient to declare his doubts, to
better describe the characteristics of this pain (as well as his
other symptoms), and to have the confidence to make effective
requests for alternative management. In this way, Mr Smith’s
legion of doctors would have been able to observe their own
mental models from a different perspective and to assess more
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objectively the next steps to be performed. In this way, any of
them could have activated a balanced thought process, avoiding
the insidious cognitive traps, particularly the overconfidence
bias (see figure 2) into which the internists in our example
inevitably fell.
Figure 2 here
Conclusion
The paradigm of cognitive balanced model is not only a
theoretical framework that allows us to create a sort of
metaphorical description of clinical reasoning. but also, the
cognitive balanced model helps focus attention on all those
mechanisms (both at individual and social level) capable of
unbalancing the clinical reasoning in one way or another. A
lack of awareness about the functioning of the mind and the
failure to elicit a shared context give rise to double imbalance
in the diagnostic process, consequently doubly-dangerous.
The active involvement of the patient can be a powerful
mechanism to balance the cognitive course also within the
realm of the diagnostic process and not only in oncology or
chronic diseases. According to our model, the involvement of
the patient represents a solid anchor for clinical reasoning in
many clinical scenarios. However, this entails a change of
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paradigm, since the physician must be able to shift from the
construction of an individual (stand-alone) mental model (much
simpler to build and to manage) to a shared mental model,
according to the paradigm of distributed cognition [28]. The
patient and the doctor, in this way, would work as a small team,
sharing information, purpose and decisions [29]. The sharing
and the co-construction of mental models to be used during the
diagnostic journey is a mechanism for increasing the collective
intelligence (in this case the community is made up of the
doctor-patient duet), which acts as an error pre-emptive tool
[29;30;31]. However, building a distributed cognitive model is
much more complex and requires skills that many doctors did
not have the opportunity to develop in their education or
professional experience. It will therefore be a task of higher
education agencies to help clinicians in this direction, in order
to significantly contribute to reduce medical errors. Even if is
possible to plan the use of sophisticated decision support
systems to prevent misdiagnosis events (as the one we
described), we argue that the first step toward a safer diagnostic
path is the active involvement of patients. Any other devices
will be useful tools to be used within a paradigm of shared
cognition between patients and physicians within a balanced
cognitive model.
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