In 1999, the Institute of Medicine released its landmark report, To Err Is Human: Building a Safer Health System, launching over a decade of intense focus on improving doctors' diagnoses within America's health-care system. But, as the recent release of the Institute of Medicine’s latest report, Improving Diagnosis in Health Care, shows, these advances have not minimized diagnostic errors in medicine. On the contrary, the rate of diagnostic errors is still much higher than any of us—health-care providers and patients alike—should accept.
Why is this the case? Although the original To Err Is Human report called for attention to all types of error, health-care quality efforts have focused primarily on reducing errors in treatment and prevention—in other words, procedural errors that can be seen, measured, and reported, like a surgeon puncturing a patient’s intestines during an appendectomy. This most recent report, however, focuses on diagnostic errors, like a physician failing to identify appendicitis in the first place. Such errors have received little attention primarily because they are cognitive errors—a failure of a health-care professional to think accurately and critically. Such errors can cause life-threatening delays in testing, interpreting results, and treating the correct problem.
With the remarkable successes in scientific knowledge and improved health-care education in the past 20 years, shouldn’t today’s medical professional be adept at diagnosis (perhaps the most basic clinical skill)? You'd think so. Yet even as medical curricula keep up with the times, the doctors they credential are still failing to prevent errors.
What medical students need is not more information, but rather more and better training in how to think about that information. Medicine, then, needs to draw some core lessons from the classical liberal arts approach.
This suggests that what medical students need is not more information, but rather more and better training in how to think about that information. For a safer health-care system, medical education needs more effective ways to teach future doctors how to think critically and solve problems about health and disease; it needs to draw some core lessons from the classical liberal arts approach.
The liberal arts have been teaching critical thinking for centuries. The aim of a liberal arts education, whether it’s through the study of Italian or government or chemistry, is not to teach specific content per se. It is, rather, to hone the ability, through practice and guided instruction, to work with information in order to identify problems, assess contexts, construct conceptual models and hypotheses, and determine what further knowledge and questions are needed to reach a solution. The academic major merely defines the content arena in which a student practices increasingly complex thinking.
In the age of Big Data, the liberal arts approach has seen its funding imperiled and many of its central ideals dismissed. But we need these cognitive skills more than ever. Now that we have Google and smartphones, facts and information, once inaccessible, are mere clicks away. This very abundance can be its own problem, requiring the ability to sift, distinguish between the topical and the relevant, and understand the big picture amidst the glut of information. Thus, in today’s professional world, obtaining information is not nearly as important as learning what to do with it—knowing how to solve complex problems in the face of ambiguity and uncertainty, and how to identify relevant facts within a background of abundant data. If these skills are important for liberal arts students, they are an absolute necessity for medical students and doctors: Indeed, they lie at the foundation of all good medical practice.
Clinical reasoning is the critical thinking of the medical world. This is where doctors, often accused of playing God, are actually supposed to think like the Biblical Creator. Good doctors learn to bring together clues from patient discussions, physical examinations, tests, and their knowledge of the human body. Like Sherlock Holmes, doctors learn to piece together clues arising from objective and subjective sources and to build a conceptual model of what may be going on. Finally, they must decide with relative accuracy a course of action based on imperfect facts and ambiguous, often rapidly changing situations.
Cognitive neuroscience and our own experiences tell us that this type of thinking is hard to teach, particularly in four short years of medical school. Once medical students master foundational knowledge, they need more liberal arts practice, and lots of it, in thinking conceptually, using concepts broadly, critically prioritizing information, knowing when to seek more information—and then knowing how to use it.
Two solutions would help: technology and economic incentives. On the technology side, medical educators are developing online cases that allow students to think their way through sticky diagnostic problems, safely making and learning from their mistakes as they go. More educational efforts that stress problem-solving and decision-making, rather than just information acquisition, can provide the tools that medical schools, pressed for curricular time and resources, need to teach clinical reasoning.
A second solution reaches even more deeply into the system. Medical care today is reimbursed based mostly on procedures, not on thinking. But for many doctors, critical reasoning is the most important procedure, the one that leads to proper diagnosis. If we begin to compensate better for smart thinking, we can create a health-care system where medical diagnostic practices are as well respected as procedurally driven fields such as radiology or surgery. More students would feel more valued in specialties not emphasizing procedures, and our medical system would become safer.
We urgently need to reduce error and improve the quality of medicine in this country. The place to start, both in the classroom and in the office, is with greater emphasis on the truth that for patients, doctors, and the health-care system itself, thinking is the most important procedure.