Pivot and cluster strategy: a preventive measure against diagnostic errors

Abstract

Diagnostic errors constitute a substantial portion of preventable medical errors. The accumulation of evidence shows that most errors result from one or more cognitive biases and a variety of debiasing strategies have been introduced. In this article, we introduce a new diagnostic strategy, the pivot and cluster strategy (PCS), encompassing both of the two mental processes in making diagnosis referred to as the intuitive process (System 1) and analytical process (System 2) in one strategy. With PCS, physicians can recall a set of most likely differential diagnoses (System 2) of an initial diagnosis made by the physicians' intuitive process (System 1), thereby enabling physicians to double check their diagnosis with two consecutive diagnostic processes. PCS is expected to reduce cognitive errors and enhance their diagnostic accuracy and validity, thereby realizing better patient outcomes and cost- and time-effective health care management.

Keywords: debiasing; diagnosis; diagnostic errors.

Figure 1

The pivot and cluster strategy is explained with a “disease map”. Notes: Suppose all diseases exist within the square frame called a “disease map” which includes all the identified diseases. Along with an initial diagnosis made by intuition of the physician, the pivot (star) diagnosis is plotted in the map. Concentric circles can be drawn a certain distance from the pivot. Dots that exist inside the circle are the clusters of this pivotal diagnosis. Diagnoses whose clinical pictures are very close to the pivotal diagnosis are distributed close to the pivotal disease. Thus, the distance between dots represents the similarity of the clinical picture of one specific diagnosis and another. Thinking of the cluster as a whole along with the pivotal diagnosis could minimize the cognitive defect in building differential diagnoses, thereby preventing biases in making diagnoses. The radius of the circle may depend on the physician’s certainty of the diagnosis. The more concern the physician has about the differential diagnoses, the greater the radius would be.

Figure 2

This figure depicts the overlap of two clusters of different pivots. Notes: Two clusters (inside dashed and solid circle) overlap with some most likely differential diagnoses. That means the two clusters resemble in clinical manifestation (eg, left-sided abdominal pain), but differs in some points in making differentials (eg, exact location, radiation of pain).