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WHAT IS METACOGNITION?
Metacognition is “thinking about thinking.”
The current popular theory of how we think is called the Dual process theory.
Dual process theory is a cognitive psychology theory that explains the different levels of information processing in individuals. It is classically defined as type I and type II thinking.
Whether we are aware of it or not, we use these types of thinking to structure our medical decision making about our patients.
SEVEN METACOGNITION HACKS TO MAKE YOU A BETTER DIAGNOSTICIAN
Early in training we are more likely to be confident but less likely to be right. Accumulating “mentally stored exemplars” will expand the accuracy of your type 1 thinking.
To solidify your type I thinking, follow up on your patients to confirm your clinical gestalt was correct.
2. Flip the switch
Deliberately “toggle” from type 1 to type 2 thinking in tough cases AND in “easy” cases to check your thought process.
Ask yourself - what evidence goes against my diagnosis? What’s the worst thing I could miss?
3. Take a diagnostic pause
Take a moment to let your cognition work. Write down your medical decision making or present the case to a colleague.
This helps “flip the switch” and also “cognitively unloads” the workup.
4. Use “cognitive forcing”
This metacognition trick helps you avoid “can’t miss” diagnoses or high-risk errors.
Examples include consistently screening for the “red flags” (e.g. fever) in low back pain or never diagnosing renal colic in an elderly patient without first thinking of a ruptured abdominal aortic aneurysm.
Using “smart phrases” in the medical decision making section of the electronic health record can serve as a checklist (and force you to consider high risk diagnoses).
5. Manage the cognitive load
Too much cognitive load triggers the “cognitive miser” function, which favors type 1 thinking and avoids type 2.
Make dispositions, unload decisions, and run the list. Clear out the “mental baggage” that is slowing you down.
6. Beware of common cognitive bias that can sabotage your decision making.
Be careful not to let how you feel about the patient affect your reasoning. It is easy to be biased against certain patient populations that are difficult.
Eg. “He’s really belligerent and rude. I bet he’s just drunk again.”
Geography does not dictate pathology.
Eg. Don’t just assume wellness in the “fast track” patient because they weren’t triaged a higher acuity.
Sometimes clinicians choose the most available diagnosis that comes to mind.
Eg. Everyone you’ve seen lately has had “the flu”, so that is the most likely the cause of your patient’s fever.
The tendency for clinicians to stick with the initial impression even as new information becomes available.
This is often worsened by confirmation bias (the tendency to accept new information only if it confirms the working diagnosis).
Eg. You immediately assume the young person with chest pain is likely musculoskeletal in origin (despite him describing radiation to both shoulders).
7. Defend against depletion.
Attend to your nutrition, hydration, and brief “cognitive pauses” (I recommend dark chocolate!).
Rest is not selfish—it’s better for our patients!
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Edited adn Posted by Jeffrey A. Holmes, MD
Campbell A et al. Profiles in patient safety: a “perfect storm” in the emergency department. Acad Emeg Med 2007; 14: 743-749. [Pubmed]
Crosskerry P. ED Cognition: any decision by anyone at any time. CJEM 2014; 16(1):13-19. [Pubmed]
Crosskerry P et al. Cognitive debiasing 1: origins of bias and theory of debiasing. BMJ Qual Saf 2014; 22:ii58-ii64. [Pdf]
Crosskerry et al. Cognitive debiasing 2: impediments to and strategies for change. BMJ Qual Saf 2013; 22:ii65-ii72. [Pubmed]
Crosskerry P. A universal model of diagnostic reasoning. Acad Med 2009; 84(8):1022-1028. [Pdf]
Kahneman D (2011) Thinking fast and slow. New York, NY: Farrar, Strauss, and Giroux. [Amazon]
Peer Reviewed by Jeffrey A Holmes, MD and Jason Hine, MD
Posted by Jeffrey A. Holmes, MD