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The Ethical Imperative to Think about Thinking: Diagnostics, Metacognition, and Medical Professionalism



While the medical ethics literature has well explored the harm to patients, families, and the integrity of the profession in failing to disclose medical errors once they occur, less often addressed are the moral and professional obligations to take all available steps to prevent errors and harm in the first instance. As an expanding body of scholarship further elucidates the causes of medical error, including the considerable extent to which medical errors, particularly in diagnostics, may be attributable to cognitive sources, insufficient progress in systematically evaluating and implementing suggested strategies for improving critical thinking skills and medical judgment is of mounting concern. Continued failure to address pervasive thinking errors in medical decisionmaking imperils patient safety and professionalism, as well as beneficence and nonmaleficence, fairness and justice. We maintain that self-reflective and metacognitive refinement of critical thinking should not be construed as optional but rather should be considered an integral part of medical education, a codified tenet of professionalism, and by extension, a moral and professional duty.



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1. de la Rochefoucauld F. Maxim 89; as quoted in Croskerry P, Nimmo, GR. Better clinical decision making and reducing diagnostic error. The Journal of the Royal College of Physicians of Edinburgh 2011;41(2):155–62, at 155.

2. Gallagher, TH, Waterman, AD, Ebers, AG, Fraser, VJ, Levinson, W. Patients and physicians’ attitudes regarding the disclosure of medical errors. JAMA 2003;289(8):1001–7.

3. Bosk, CL. Forgive and Remember: Managing Medical Failure. Chicago: University of Chicago Press; 1979.

4. Graber, ML, Franklin, N, Gordon, R. Diagnostic error in internal medicine. Archives of Internal Medicine 2005;165(13):1493–9.

5. Graber, ML, Carlson, B. Diagnostic error: The hidden epidemic. Physician Executive 2011;37(6):1219.

6. ABIM Foundation, ACP-ASIM Foundation, European Federation of Internal Medicine. Medical professionalism in the new millennium: A physician charter. Annals of Internal Medicine 2002;136(3):243–6.

7. Institute of Medicine. To Err Is Human: Building a Safer Health System—Institute of Medicine; available at (last accessed 16 July 2013).

8. Wachter, RM. Why diagnostic errors don’t get any respect—and what can be done about them. Health Affairs 2010;29(9):1605–10.

9. Groopman, J. How Doctors Think. New York: Houghton Mifflin; 2007.

10. Croskerry, P. A universal model of diagnostic reasoning. Academic Medicine: Journal of the Association of American Medical Colleges 2009;84(8):1022–8.

11. Croskerry, P. From mindless to mindful practice—Cognitive bias and clinical decision making. New England Journal of Medicine 2013;368(26):2445–8.

12. Pelaccia, T, Tardif, J, Trilby, E, Charlin, B. An analysis of clinical reasoning through a recent and comprehensive approach: The dual-process theory. Medical Education Online 2011;16:5890.

13. Berner, ES, Graber, ML. Overconfidence as a cause of diagnostic error in medicine. The American Journal of Medicine 2008;121(5):S2S23.

14. See note 7, Institute of Medicine.

15. See note 8, Wachter 2010.

16. See note 8, Wachter 2010, at 1605.

17. Newman-Toker DE, Pronovost PJ. Diagnostic errors—The next frontier for patient safety. JAMA 2009;301(10):1060–2, at 1060.

18. See note 4, Graber et al. 2005, at 1493.

19. Saber Tehrani AS, Lee HW, Mathews SC, Shore A, Makary MA, Pronovost et al. 25-year summary of US malpractice claims for diagnostic errors 1986–2010: An analysis from the National Practitioner Data Bank. BMJ Quality & Safety 2013; available at (last accessed 21 July 2013).

20. See note 19, Saber Tehrani et al. 2013, at 1.

21. See note 5, Graber, Carlson 2011.

22. Kahneman, D. Thinking Fast and Slow. New York: Farrar, Straus and Giroux; 2011.

23. Tversky, A, Kahneman, D. Judgment under uncertainty: Heuristics and biases. Science 1974;185:1124–31.

24. See note 22, Kahneman 2011.

25. Stanovich, KE, West, RF. Individual differences in reasoning: Implications for the rationality debate? Behavioral and Brain Sciences 2000;23(5):645–65.

26. See note 22, Kahneman 2011.

27. See note 10, Croskerry 2009.

28. See note 12, Pelaccia et al. 2011.

29. See note 13, Berner, Graber 2008.

30. Croskerry, P. The cognitive imperative: Thinking about how we think. Academic Emergency Medicine 2000;7(11):1223–31.

31. Croskerry, P, Norman, G. Overconfidence in clinical decision making. The American Journal of Medicine 2008;121(5 Suppl):S24S29.

32. See note 31, Croskerry, Norman 2008, at S28.

33. See note 10, Croskerry 2009.

34. See note 10, Croskerry 2009, at 1026.

35. Djulbegovic, B, Hozo, I, Beckstead, J, Tsalatsanis, A, Pauker, SG. Dual processing model of medical decision-making. BMC Medical Informatics and Decision Making 2012;12(1):94.

36. Marcum, JA. An integrated model of clinical reasoning: Dual-process theory of cognition and metacognition. Journal of Evaluation in Clinical Practice 2012;18(5):954–61.

37. See note 11, Croskerry 2013.

38. Dunlosky J, Metcalfe J. Metacognition. Beverly Hills, CA: SAGE Publications; 2009.

39. See note 11, Croskerry 2013, at 2447–8.

40. See note 31, Croskerry, Norman 2008.

41. See note 1, Croskerry, Nimmo 2011.

42. See note 10, Croskerry 2009.

43. See note 31, Croskerry, Norman 2008.

44. Norman, G. Dual processing and diagnostic errors. Advances in Health Sciences Education: Theory and Practice 2009;14(1 Suppl):3749.

45. Mamede, S, van Gog, T, van den Berge, K, Rikers, RMJP, van Saase, JLCM, van Guldener, C, Schmidt, HG. Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents. JAMA 2010;304(11):1198–203.

46. Bing-You RG, Trowbridge RL. Why medical educators may be failing at feedback. JAMA 2009;302(12):1330–1.

47. See note 12, Pelaccia et al. 2011.

48. See note 4, Graber et al. 2005.

49. Rudolph, JW, Morrison, JB. Sidestepping superstitious learning, ambiguity, and other roadblocks: A feedback model of diagnostic problem solving. The American Journal of Medicine 2008;121(5 Suppl):S34S37.

50. See note 46, Bing-You, Trowbridge 2009.

51. Smith, KA. To keep an incessant watch. Academic Emergency Medicine 2011;18(5):545–8.

52. See note 8, Wachter 2010.

53. See note 17, Newman-Toker, Pronovost 2009.

54. See note 5, Graber, Carlson 2011.

55. Schiff, GD, Hasan, O, Kim, S, Abrams, R, Cosby, K, Lambert, BL, et al.Diagnostic error in medicine: Analysis of 583 physician-reported errors. Archives of Internal Medicine 2009;169(20):1881–7.

56. See note 8, Wachter 2010, at 1607.

57. Groopman, J. What’s missing in medical thinking. Bulletin of the American Academy 2010;53–8, at 55.

58. Beauchamp, TL, Childress, JF. Principles of Biomedical Ethics. New York: Oxford University Press; 2001.

59. Tyson P. The Hippocratic Oath today. NOVA; available at (last accessed 26 July 2013).

60. Pellegrino, ED. Toward an expanded medical ethics: The Hippocratic ethic revisited. In: Veatch, RM, ed. Cross Cultural Perspectives in Medical Ethics. Boston: Jones and Bartlett; 2000;4153, at 48.

61. Pellegrino, ED. The medical profession as a moral community. Bulletin of the New York Academy of Medicine 1990;66(3):221–32, at 221.

62. See note 61, Pellegrino 1990, at 230.

63. See note 11, Croskerry 2013.

64. See note 9, Groopman 2007.

65. See note 30, Croskerry 2000.

66. Jonsen, A. The Birth of Bioethics. New York: Oxford University Press; 1998, at 7.

67. Kaplan, B. Evaluating informatics applications—Clinical Decision Support Systems literature review. International Journal of Medical Informatics 2001;64(1):1537.

68. See note 19, Saber Tehrani et al. 2013.

69. See note 19, Saber Tehrani et al. 2013.

70. See note 4, Graber et al. 2005.

71. See note 8, Wachter 2010.

72. See note 35, Djulbegovic et al. 2012.

73. See note 36, Marcum 2012.

74. See note 10, Croskerry 2009.

75. See note 17, Newman-Toker, Pronovost 2009, at 1061.

76. Rawls, J. A Theory of Justice. Cambridge, MA: Belknap; 1971.

77. Fins, JJ, Pohl, B, Doukas, DJ. In praise of the humanities in academic medicine: Values, metrics, and ethics in uncertain times. Cambridge Quarterly of Healthcare Ethics 2013;22(4):355–64, at 360.

78. Ariely, D. Predictably Irrational. New York: Harper; 2009.

79. Kahneman D. The marvels and flaws of intuitive thinking: Edge master class 2011; available at (last accessed 18 July 2013).

80. See note 38, Dunlosky, Metcalfe 2009.

81. See note 46, Bing-You, Trowbridge 2009.

82. See note 51, Smith 2011.

83. See note 55, Schiff et al. 2009, at 1886.

84. Fins JJ. From desk to bedside: Profiles in bioethics. American Society for Bioethics and Humanities; available at (last accessed 14 Aug 2013).

85. Dewey J. How We Think. Boston: DC Heath; 1910 (original publication). Dover Edition, 1997; available at (last accessed 22 Aug 2013).

86. Fins, JJ. A Palliative Ethic of Care: Clinical Wisdom at Life’s End. Sudbury, MA: Jones and Bartlett; 2006, at xxi.

87. See note 8, Wachter 2010.

88. See note 11, Croskerry 2013.

89. See note 9, Groopman 2007.

90. See note 61, Pellegrino 1990.

91. See note 5, Graber, Carlson 2011.

92. See note 17, Newman-Toker, Pronovost 2009.

93. McDonald, KM, Matesic, B, Contopoulos-Ioannidis, DG, Lonhart, J, Schmidt, E, Pineda, N, Ioannidis, JP. Patient safety strategies targeted at diagnostic errors: A systematic review. Annals of Internal Medicine 2013;158(5 Part 2):381–9.

94. See note 93, McDonald et al. 2013.

95. Stark, M. Reconciling bioethics with health care strategies born of behavioral economics and psychology. The American Journal of Bioethics 2012;12(2):2830.

96. See note 30, Croskerry 2000.



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