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The unexamined thought
Croskerry, P. From mindless to mindful practice - Cognitive bias and clinical decision making. NEJM 2013, 368(26), 2445-2448.
Reviewed by Karen Forbes

What is this article about?
This commentary focuses on the issue of cognitive bias and how it relates to clinical decision making. Croskerry describes the influences of cognitive bias, and explains that problems with a clinician's thinking are more likely to lead to diagnostic error than a lack of knowledge itself. Furthermore, knowledge of the dual process system of cognitive processing helps us understand how and when cognitive failures may occur. Type 1 (intuitive) processing is highly efficient and often serves clinicians well, but is more likely to be influenced by biases and result in thinking failures. On the other hand, Type 2 (analytic) processing is more "resource intensive" and not practical for all clinical decisions, but is less likely to result in cognitive failures (although is certainly not free from bias). The author does not state that one system is superior, but rather he advocates that clinicians need to be aware of how biases can influence their thinking, and only when that is done can efforts be made to reduce these influences.

What are the implications?
In order to address the issue of cognitive bias, Croskerry advocates that critical thinking is a skill, and should be taught and developed throughout medical education, beginning at the undergraduate level and continuing through postgraduate training and into clinical practice. He argues that only through awareness of the influences of biases can individuals become mindful of such biases in their thinking, so as to develop effective "debiasing" strategies. This leads us to consider how we as educators may promote the teaching of critical thinking in medical school curricula as a fundamental skill for our learners. Furthermore, we are challenged as clinicians to be cognizant of biases in our own thinking processes.

Editor's note: This thought-provoking article deserves to be read. The author wittingly concludes "to paraphrase Socrates, the unexamined thought is not worth thinking" :) (SLB).

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