“Reason itself is fallible, and this fallibility must find a place in our logic.” - Nicola Abbagnano
Decision making in Emergency Medicine is intensely complex and it also the defining characteristic of the practice of Emergency Medicine. To outside eyes we may seem to be a specialty of action: chest tubes, intubations, heroic resuscitations with massive amounts of blood products and IV infusions. In truth none of the “action” of our specialty, the big sexy things they make into TV shows and movies, occurs without rapid, precise, and accurate thinking and decision making. But the Emergency Department can be a hostile environment to the decision making process. And, I’m not just talking about the noisy environment, the multiple interruptions, the patients with a wide variety of chief complaints and acuity seen in quick succession. There’s seemingly a thousand different hurdles between the instant a patient recognizes that something might be wrong with them and the moment a clinician diagnoses the problem.
To this point when we as emergency physicians have talked about improving our diagnostic skills (and it is much needed), we have tended to focus on the last step in the process diagramed above (1). It’s a good starting point. We have to know the processes by which we go about making diagnoses and the errors and biases inherent in our decision making (and to that end you can use the cognitive biases flashcards at the bottom of this post to help you learn and remember). But, as an additive to this focus on metacognition (thinking about the way we think), we should seek to bring some fallibilism to the bedside as well.
What is fallibilism? Fallibilism is “the philosophical principle that human beings could be wrong about their beliefs, expectations, or their understanding of the world.”(2) It differs from skepticism which looks to question current knowledge, abandon whatever knowledge doesn’t have a logical basis, and search for the true absolute knowledge that underpins the workings of the world. Fallibilism instead would suggest that there may be no absolute truth (certainly no absolute truth as any one person could experience) and that there is no need to abandon current knowledge (only to be open to new information that could change our understanding of that knowledge). As it is a parallel to the scientific process, it’s a concept with which every physician should be comfortable.
So what the heck does this mean at the bedside? Well it’s not just the long game of understanding that everything you learned in medical school may one day turn out to be untrue. To be a fallibilist at the bedside is to exercise the understanding the very ‘facts of the case’ of the patient presenting in front of you may indeed be wrong. It means always being open to the possibility that you are wrong about the way you are interpreting the patient’s presentation and the treatments they need. It means being open to new information that might change your diagnostic or therapeutic actions. Fallibilism is the ultimate cognitive forcing strategy. (3) Only when you truly let yourself be open to the possibility you are wrong, can you undergo an honest search for information that runs counter to your version of reality.
Taking a fallibilistic approach also allows you to be more open in discussions with consultants. You think the GI physician should come in at 1 AM to scope a hypotensive upper GI bleed? You think the trauma surgeon has to take a patient to the OR right now? Maybe you are right, but maybe you’re not. You can use your fallibility as an opening to explore your colleagues decision making. “I’m sorry, I might be wrong here, but I really thought that these patient’s should go to the OR (or get procedure X). Can you tell me why you don’t think this patient needs to go to the OR (or to get procedure X)?” What you get from that conversation is going to be much more meaningful than the battle of wills that typically results. Maybe the consultant doesn’t fully understand the patient’s presentation as you did? Maybe they understand the patient’s presentation but know something about the literature you don’t, or know something about the expected course of the patient that you don’t?
Clinical decision making is incredibly difficult and figuring out how to get better at it is equally as challenging. But as a starting point, consider actively fostering a mindset open to the possibility of failure and fallibility.
1.) Croskerry, P. (2000) The Cognitive Imperative: Thinking about How We Think. Academic Emergency Medicine. vol. 7, no. 11. 1223-1231
2.) Fallibilism. (2016, June 5). In Wikipedia, The Free Encyclopedia. Retrieved 12:59, July 28, 2016, from https://en.wikipedia.org/w/index.php?title=Fallibilism&oldid=723838555
3.) Croskerry, P. (2003) Cognitive Forcing Strategies in Clinical Decision Making. Annals of Emergency Medicine. vol. 41, no. 1. 110-120