Gut feelings don’t count in diagnoses

Dr. Pat Croskerry recalls a medical student once telling him he had a "gut feeling" about a patient diagnosis. "You are not allowed to have a 'gut feeling' about a patient," Croskerry told the student. "Find out what is really going on."

As Professor in Emergency Medicine at Dalhousie University, Halifax, and a leading international advocate for patient safety, Croskerry was the featured speaker at BIDMC's 4th annual Silverman Institute Symposium on Health Care Quality and Safety. The symposium also featured a poster session reflecting the work of 90 Improvement Project Teams from across the medical center.

"We must monitor ourselves, reflect on what we are doing and constantly ask ourselves, "What did I just do?," he says.

Delivering a lecture named in honor of former BIDMC Chief Operating Officer Michael Epstein, MD, Croskerry said the "safest hospital for medical decision-making ... must continuously support and challenge the way clinicians make diagnostic decisions. This means, in part, teaching residents and veteran clinicians alike a new way of thinking and approaching the correct diagnosis.

"The decision makers need to understand how decisions get made ... how individual factors influence critical decision making," he said.

According to Croskerry, these factors include:
• Personality;
• Decision-making style
• Gender
• Over-confidence
• Risk aversion/conservatism;
• Aging
• Fatigue/sleep deprivation

In the panel discussion that followed the keynote lecture, Dr. Richard Schwartzstein, BIDMC's Vice President of Medical Education, noted the reality that while he and others are teaching students and residents not to jump to conclusions or relay on rote memory (to understand, not just know), the "fact is that when they arrive on the wards as housestaff they are rewarded for making the fastest, largest, differential diagnosis."

"The bottom line is that we have to monitor ourselves and learn how to best deal with the two types of thinking (intuitive and analytic)," Croskerry said during grand rounds. "We need to determine what is optimal medical decision-making. We need to know and understand the duel processing model, educate clinicians, "train" the intuitive process and promote the process of reflection on decision-making."