28 avril 2022

La poursuite de l’excellence diagnostique selon Croskerry

Aim. Recently, a growing awareness has developed of the extraordinary complexity of factors that influence the clinical reasoning underpinning the diagnostic process. The aim of the present report is to delineate these factors and suggest strategies for dealing more effectively with this complexity. Method. Six major clusters of factors are described here : (A) individual characteristics of the decision maker, (B) individual intellectual and cognitive styles, (C) ambient and homeostatic factors, (D) factors in the work environment including team factors, (E) characteristics of the medical condition, and (F) factors associated with the patient. Additional factors, such as health care systems, culture, politics, and others are also important. Results. A review of the literature suggests that most clinicians trained under existing methods achieve a level of expertise presently referred to as “routine” or “classic.” The results of studies of diagnostic failure, however, suggest that this level of expertise has proved insufficient. A growing literature suggests that more effective clinical decision might be achieved through adaptive reasoning, leading to enhanced levels of expertise and mastery. Conclusions. It is proposed here that adaptive expertise may be achieved through emphasizing additional features of the reasoning process : being aware of the inhibitors and facilitators of rationality ; pursuing the standards of critical thinking ; developing a comprehensive awareness of cognitive and affective biases and how to mitigate them ; developing a similar depth and understanding of logic and its fallacies ; engaging metacognitive processes such as reflection and mindfulness ; and through approaches embracing creativity, lateral thinking, and innovation.

  • Même si le résumé laisse croire qu’il s’agit d’un article à base expérimentale, il n’en est rien : il s’agit d’un article de commentaires s’ajoutant à quelques autres déjà publiés dans JAMA, sur le thème de l’excellence diagnostique. Clairement rédigé, non polémique, il expose les idées très typées de son auteur, fidèle thuriféraire de Daniel Kahneman, et pourfendeur de biais cognitifs. Tout cela semble frappé au coin du bon sens, et n’attend toujours que des arguments expérimentaux. Jusqu’ici, à de rares exceptions près, toutes les tentatives d’influencer lesdits biais n’ont pas vraiment prouvé qu’elles amélioraient la performance diagnostique, mais elles ne peuvent pas être nuisibles. Soulignons l’importance de « l’intelligence collective » : le diagnostic est un sport d’équipe. Et celle de l’amélioration des connaissances : difficile de diagnostiquer une pathologie dont on ignore tout. Mais ceci est accessoire dans l’esprit de l’auteur.

Croskerry P. The rational diagnostician and achieving diagnostic excellence. JAMA 2022;40(8):803-8. Doi : 10.1001/jama.2021.24988.