Two complementary perspective articles are worth a look:

• NEJM 2013; 368: 2445-48
• NEJM 2013; 368: 2448-50.

The first article discusses cognitive bias. The authors note that diagnostic failure rates are typically in the range of 10-15%, but lower for “visual specialties” like radiology and pathology where the rate is closer to 2%.  Why is the diagnostic failure rate so high?  The authors describe the mind’s vulnerability due to biases, and assumptions. “More than 100 biases affecting clinical decision-making have been described.”

The authors note that decision-making relies on either intuitive processes or analytic processes.  Intuitive processes are either hard-wired or acquired through repeated experiences.  These processes are subconscious and fast.  In contrast, analytic processes are deliberate, slower, but much more reliable.  “Despite the ubiquity and usefulness of intuitions, they are not reliable enough for us to use them to send a spaceship to Mars.”  In more complex issues, analytic processes are needed.

The main problem with analytical thinking is that it is more time-consuming and more resource-intensive.  “It would be impractical to deal with each clinical decision analytically.”  Keeping mindful of when critical thinking is needed is the challenge.

The second article discusses uncertainty, especially with regard to prognosis.  Key points:

• Normalize the issue of uncertainty with patients. “Patients are bombarded…with the notion that high-tech advances…have resulted in definitive answers.” “Clinicians should be honest…’I understand that you want more accurate information about the future.  The reality is that it’s like predicting the weather–we can never be absolutely certain about the future. I wish I could be more certain.'”
• Help families manage uncertainty.  “The search for certainty may impede the ability …to live in the present.” Clinicians should avoid propagating this issue.  Instead of “We need more time to be sure,” the authors suggest “What can we do to help you now, given that we are unsure of exactly what the future will bring?”