Taking the Myth and Mystery out of Diag - nostic Decision Making

Several recent books have addressed " How Doctors Think, " with emphasis on diagnostic decision making and the sources of diagnostic error. National venues now target the problem of diagnostic error and new studies highlight the high levels of costly and unnecessary test ordering, much of which is related to ineffective diagnostic processes. And, finally, teaching clinical reasoning is still considered a difficult curriculum to master. Why do physicians have difficulty in making a diagnosis? Is making a diagnosis unique to medical decision making? Given the fact that every day we use " diagnostic decision making " to solve problems at work, at home or at play, why is clinical reasoning and diagnostic decision making in the clinical setting so difficult to learn and master? And why is diagnostic decision making any different than the reasoning we use to solve problems in our daily lives? Doesn't finding your car keys require diagnostic decision making? Clearly, any adult is faced with problems that require solutions on a daily basis and is it not reasonable to use the term " diagnostic decision making " to explain these processes? Is there something uniquely different or difficult when we solve problems in the practice of medicine? Are physicians any different from auto mechanics who use reasoning and diagnostic tools to identify problems under the hood? I don't think so. In summary, as human beings, we have the capacity to reason and have been constantly solving problems since childhood; clearly, some of us are better diagnosticians than others. However, there is absolutely no rationale that the modus operandi for clinical reasoning and decision making in medicine is unique or different from that used in daily life. So what is the nature of the problem? I believe there are three fundamental steps in effective decision making that, if unmet, result in an ineffective diagnostic process and potential diagnostic error. First is command of knowledge about the subject; if you don't know what something (continued)