The Cognitive Imperative Thinking about How We Think

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<ul><li><p>ACADEMIC EMERGENCY MEDICINE November 2000, Volume 7, Number 11 1223</p><p>The Cognitive Imperative: Thinking aboutHow We Think</p><p>PAT CROSKERRY, MD, PHD</p><p>Abstract. There are three domains of expertise re-quired for consistently effective performance in emer-gency medicine (EM): procedural, affective, and cog-nitive. Most of the activity is performed in thecognitive domain. Studies in the cognitive scienceshave focused on a number of common and predictablebiases in the thinking process, many of which arerelevant to the practice of EM. It is important tounderstand these biases and how they might influ-ence clinical decision-making behavior. Among thespecialities, EM provides a unique clinical milieu ofinconstancy, uncertainty, variety, and complexity. In-jury and illness are seen within narrow time win-dows, often under pressured ambient conditions.These operating characteristics force practitioners to</p><p>adopt a distinctive blend of thinking strategies. Prin-cipal among them is the use of heuristics, a form ofabbreviated thinking that often leads to successfuloutcomes but that occasionally may result in error. Anumber of opportunities exist to overcome interdis-ciplinary, linguistic, and other historical obstacles todevelop a sound approach to understanding how wethink in EM. This will lead to a better awareness ofour cognitive processes, an improved capacity toteach effectively about cognitive strategies, and,ultimately, the minimization or avoidance of clinicalerror. Key words: emergency medicine; cognition;errors; decision making; heuristics. ACADEMICEMERGENCY MEDICINE 2000; 7:12231231</p><p>THERE are three major skill sets in the per-formance repertoire of emergency physicians(EPs): procedural, affective, and cognitive.1 It mayappear to outside observers, as well as to manywithin the profession, that emergency medicine(EM) is predominantly action-oriented and thatprocedural skills are, therefore, the most impor-tant of the three. Indeed, during training, a con-siderable emphasis is directed at the acquisitionand retention of skills such as intubation, woundrepair, the insertion of chest tubes and centrallines, diagnostic peritoneal lavage, lumbar punc-ture, and cast application. This procedural skill setis tangible, well defined and teachable. While pro-cedural skills are important and integral to an ef-fective performance in the emergency department(ED), they comprise a relatively small part of theoverall activity of EPs. Most of our time, in fact, isengaged in cognitive behavior; it is the preponder-</p><p>From the Department of Emergency Medicine, Dalhousie Uni-versity, Queen Elizabeth II Health Sciences Center, Halifax,Nova Scotia, and the Department of Emergency Medicine,Dartmouth General Hospital, Dartmouth, Nova Scotia, Can-ada (PC).Received February 28, 2000; revision received March 29, 2000;accepted July 6, 2000.Supported in part by a grant from the Department of Emer-gency Medicine at Dalhousie University, Halifax, Nova Scotia,Canada.Address for correspondence and reprints: Pat Croskerry, MD,PhD, Department of Emergency Medicine, Dartmouth GeneralHospital, 325 Pleasant Street, Dartmouth, Nova Scotia, Can-ada B2Y 4G8. Fax: 902-465-8579; e-mail: dghosp@crhb.ns.ca orxkerry@accesscable.net</p><p>ant substance of EM. Surprisingly, it has attractedrelatively little attention, perhaps because of anundervalued regard for the importance of exactlyhow we think. In a recent report, medical educa-tors concluded that EM health care workers wereoften . . . not consciously aware of how they eval-uate evidence and cope with decision complexity.2</p><p>Proficiency in the cognitive domain, comparedwith that in procedural skills, is less easily de-fined, involves a much broader range of possibili-ties, and would appear to be less easily taught.Kassirer, in 1995, recognized the problem veryclearly:</p><p>Research in the cognitive aspects of clinical problem-solving has ebbed, and a comprehensive theory of di-agnostic and therapeutic problem-solving is not yetat hand. No matter how advanced our technology be-comes, and no matter how far our computer systemsevolve, the cognitive tactics and strategies of the cli-nician-problem-solver are not likely to be replaced inthe foreseeable future. Those who are responsible forteaching students and residents these skills shouldtry to identify clearly, separate, and then extractthese critically important cognitive tasks fromcourses that encompass myriad unrelated skills andknowledge. . . . They should recognize that these crit-ical cognitive skills constitute a specific body ofknowledge and should find imaginative ways ofteaching them.3</p><p>The problem that faces us involves thinkingabout the ways we think. We need to develop moreawareness of, and insight into, the cognitive pro-</p></li><li><p>1224 COGNITION Croskerry HOW WE THINK</p><p>cesses involved in decision making. If we under-stood more about these processes, we might betterunderstand how cognitive errors occur, and how wemight best teach others to minimize or avoid them.The argument is proposed here that the special mi-lieu and prevailing conditions of EM impose a dif-ferent style of thinking, with a unique blend of cog-nitive strategies, on those who work there.Importantly, there is a need to understand whatcognitive science has to offer EM.</p><p>The remaining skill set is in the domain of af-fective behavior, which again is ill defined and lesstangible. Emergency physicians and nurses haveto deal with a broad range of emotions shown bycolleagues, patients, and their relatives andfriends. Many of these interactions are probablymediated by important experiential factors involv-ing social transference and countertransferencephenomena4: our likes and dislikes of others maybe irrationally based on significant exemplars inour own past. Inappropriate affective responses to-ward others may also arise through causal attri-bution, the process by which we make value judg-ments about the behavior of others on the basis ofsituational or dispositional factors.5 More empha-sis should be placed on the cognitive managementof situations engendering a range of emotions thatmay run the full gamut from empathy to hostility.Emotional factors clearly impact on decision mak-ing and can lead to error. We do not make gooddecisions when our viscera are aroused. Again, asfor cognitive behavior, we need to be thinkingabout how we feel, and understand the impact thismay have on clinical decision making.</p><p>Cognitive and affective behaviors are largelycovert, and involve a most critical activity, that ofmaking decisions about patient diagnosis, manage-ment, and disposition. Despite a comprehensiveliterature on medical decision making, this areahas yet to be systematically addressed within thediscipline of EM. Historically, a greater emphasishas been placed on what we do rather than onwhat, or how, we think. All three components ofperformance influence each other; affective expe-riences clearly influence what we think,6 and cog-nition ultimately determines what we will actuallydo. For good calibration of performance7 in the ED,physicians must be knowledgeable and competentin all three domains.</p><p>Developing a perceptual awareness of how wethink and feel is a necessary first step in under-standing our cognitive behavior. William Jamesemphasized that in order to perceive something wemust not only be conscious of it but also be payingattention. For example, once a visual illusion hasbeen explained to us, we can focus attention on thecritical aspects of the signal and avoid being influ-enced to the same extent by distracting visual</p><p>noise.8 Perceptual accuracy, therefore, requiresattention. We need to be thinking about how wethink and feel.</p><p>THEORY AND PRACTICE</p><p>An argument might reasonably be made that thereare enough distinctive features of EM to set itaside from mainstream medicine, and that both itstheory and practice merit special treatment. A ma-jor difficulty in developing an approach to the cog-nitive behavior that underlies clinical decisionmaking in EM is that we do not yet have a distincttheoretical framework for the discipline. First,there is a need to develop an epistemological foun-dation, i.e., a theoretical basis for the method andgrounds through which knowledge will be ac-quired. On this we can build a sound cognitive the-ory that will be uniquely adapted to the specializedrequirements of EM. The final step will be the de-velopment of specific cognitive skill sets that areeasily understood and teachable. Importantly, thetheory must complement practice.</p><p>Schein9 described a hierarchical order of prior-ities in strategies for the acquisition of knowledge.At the topmost end are epistemological considera-tions that require theorizing about the processes,methods, and grounds upon which knowledge isdeveloped, what he referred to as the underlyingdiscipline or basic science component.</p><p>The next level has been termed the applied sci-ence, engineering,9 or normative10 component. Inthe cognitive domain, this refers to the empiricaltheory upon which practitioners base their reason-ing, and that underlies the clinical decision-mak-ing process. Earlier models of clinical decisionmaking, now referred to as classical decision the-ory, aimed at providing a formal, axiomatic meth-odology through which a clear endpoint could bereached. This process was based on utility theoryand probability theory,11 with the Bayesian rule al-lowing an algebraic computation of diagnosticprobabilities.12 Some form of probabilistic reason-ing, though less mathematical, underlies the var-ious approaches others have taken toward clinicaldecision making, such as the classic hypothetico-deductive strategy,13 pattern recognition,14 the al-gorithmic method,15 and the exhaustive strategy.16</p><p>The lower level of Scheins hierarchy, but thatwhich has the most significance for EPs andnurses, is characterized as descriptive,10 reflectingthe skills and attitudinal component,9 or what ac-tually happens in clinical practice. Traditionally,these skills were acquired toward the end of formalmedical training,17 although newer, innovative pro-grams introduce them at earlier stages.18</p><p>A historical problem for physicians in general,19</p><p>and EPs in particular,20 is that the upper, theoret-</p></li><li><p>ACADEMIC EMERGENCY MEDICINE November 2000, Volume 7, Number 11 1225</p><p>ical levels of this hierarchy have been perceived assomewhat ethereal. They have been characterizedas in vitro, the concern lying more with the needto perform at an in vivo level.21 Schon describesthis as the rigor or relevance dilemma,17 and Rea-son sees it as the cognitive reality departing fromthe formalized ideal.22 Elsewhere, somewhat moreharshly, it is referred to as the difference betweenclinical reality and abstract imagery.19 The mes-sage is fairly clear: for any theory of clinical deci-sion analysis to be acceptable to EPs and nurses,it must be practical and comprehensible, and mustenjoy some features of common sense.</p><p>In his excellent critique of this dichotomy be-tween the mathematical approach toward decisionmaking and the science of clinical reality, Feinsteinmakes the important objection that Bayesian clin-ical logic drives toward a diagnostic endpoint.19 Asimilar criticism is implicit in Rasmussens inter-pretation of medical diagnosis as a dynamic pro-cess involving a choice of possible actions ratherthan as an isolated endpoint.23 These viewpointsrepresent a subtle but important change of empha-sis in the theoretical basis of clinical decision mak-ing because EPs are often more concerned withmanagement or therapeutic action than withachieving diagnostic closure. There are some ob-vious pitfalls associated with the latter.1,8</p><p>More recently, the classical or normative theoryhas come under renewed attack from proponentsof the naturalistic model of decision making(NDM). This model has considerable appeal be-cause many of its features and properties are con-gruent with the unique operating characteristics ofEDs: the model avoids rigorous analytical strate-gies and emphasizes economy of thought and ac-tion; it accepts that decision making is more drivenby situational variables, may be influenced by re-source limitations, and temporally evolves; it ac-knowledges the important role of perceptual pro-cessing, varying cognitive strategies, and theircost, as well as the influence of past experience andhabit; and importantly, it emphasizes competencenot failure, and it can accommodate a teamworkapproach.24 It may well be what EPs are lookingfor. It more closely approximates their working en-vironment, and provides a realistic and practicalframework in which cognitive processes and clini-cal reasoning can be examined.</p><p>The goal, then, will be to find effective ways inwhich advances made at the theoretical levels areeffectively communicated to the grassroots levelamidst the variable topography of the EM land-scape. This is the place that Schon refers to as theswampy lowlands,17 where messy and indeter-minate problems will be encountered. This prob-lem is not unique to EM. Others have identifiedsimilar gaps between what has converged into ac-</p><p>cepted, theoretical dogma and the demands of real-world practice.17 Emergency physicians frequentlydemonstrate their ability to use available conver-gent knowledge in a particular area and tailor itto the unique demands of a specific situation.Schein9 refers to this as divergent thinking, thedivergence amounting to cognitive adaptationwhere theoretical dogma has failed. Thus, EPs andnurses will be interested particularly in the flexi-bility and comprehensiveness of the theoretical de-velopments they are offered, and how they willtranslate into practice on the front line. Such the-ory should properly have its basis in cognitive sci-ence. To begin the process, we should give someconsideration to the ways in which we think, andhow we might reduce errors in our thinking.</p><p>REASONING STRATEGIES</p><p>There are three basic reasoning strategies, moral,deductive, and inductive,25 and all have applicationin the ED. We cannot escape moral reasoning andjudgmental behavior in the ED. Everyone willhave some moral stance toward how patientsought to be treated, involving what he or she mightbelieve are right or wrong treatments, regardlessof the consensus of experts. This is well illustratedin the management of psychiatric patients in theED. Some studies have shown that emergency per-sonnel may actually increase the risk of suicide indepressed patients,26,27 such iatrogenic contribu-tions to suicide probably having their origin incountertransference.28 Moral reasoning clearly hasno logical validity, depending, as it does, on indi-vidual and prevailing societal and cultural values.It is distinguished from judgments of taste, where,for example, we express opinions about what welike and dislike, often as a result of attribution, theprocess through which we might make erroneousinferences about patients personal qualities on thebasis of their behavior,29 or, again, through trans-ference and countertransference feeli...</p></li></ul>

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