Making Metacognition Work for You


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  • 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.



1. Practice

  • 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.

  • Affective bias:

    • 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.”

  • Framing bias:

    • Geography does not dictate pathology.

    • Eg. Don’t just assume wellness in the “fast track” patient because they weren’t triaged a higher acuity.

  • Availability bias

    • 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.

  • Anchoring bias

    • 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


  1. Campbell A et al. Profiles in patient safety: a “perfect storm” in the emergency department. Acad Emeg Med 2007; 14: 743-749. [Pubmed]

  2. Crosskerry P.  ED Cognition: any decision by anyone at any time. CJEM 2014; 16(1):13-19. [Pubmed]

  3. Crosskerry P et al.  Cognitive debiasing 1: origins of bias and theory of debiasing.  BMJ Qual Saf 2014; 22:ii58-ii64. [Pdf]

  4. Crosskerry et al. Cognitive debiasing 2: impediments to and strategies for change. BMJ Qual Saf 2013; 22:ii65-ii72. [Pubmed]

  5. Crosskerry P.  A universal model of diagnostic reasoning.  Acad Med 2009; 84(8):1022-1028. [Pdf]

  6. 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