Medicine
Sharpen judgement. Recognise errors. Secure decision quality.
Medical errors arise less often from a lack of expertise than from the way experienced professionals judge under time pressure, fatigue and uncertainty.
A study of 387 emergency physicians found that cognitive factors were involved in 96 per cent of all diagnostic errors (Kunitomo et al., 2022).
Expertise accelerates thinking but does not make it infallible. That is a structural property of the human judgement system, and it applies to anyone who makes decisions under time pressure and uncertainty.
I help clinical teams and medical leaders make these patterns visible and secure decision quality at a structural level.
Where judgement quality breaks down in medicine
Diagnostics and clinical practice
Early information anchors judgement disproportionately (anchoring bias). The search for a diagnosis ends too soon once a plausible explanation has been found (premature closure). Diagnoses that have been communicated once persist through handovers without being re-examined (diagnosis momentum).
These mechanisms are particularly powerful in medicine because time pressure, incomplete information and high stakes all occur simultaneously. What feels clinically coherent is not always correct.
Handovers and team judgement
Diagnoses that are repeated in handovers gain social momentum. The more people adopt an assessment without re-examining it, the more firmly it takes hold, regardless of the actual state of the evidence. Nobody asks what current basis the diagnosis actually rests on. What looks like a communication problem is almost always a structural judgement problem.
Noise in clinical judgement
Even with identical cases, competent professionals reach markedly different diagnoses and treatment decisions. In two large studies on mammography reporting, the sensitivity of experienced radiologists varied between 31 and 96 per cent for identical images, and in a later analysis of over one million images between 0 and 100 per cent (Elmore et al., 1994; Elmore et al., 2009). This is not incompetence but a structural feature of every judgement system. Noise is just as consequential as bias, but considerably harder to detect, because it has no discernible direction and therefore remains invisible in everyday practice.
Workload and context effects
Judgements shift with fatigue, time of day and the sequential processing of cases. Resident physicians working regular shifts of over 24 hours were found in studies to be 5.6 times more likely to be involved in serious diagnostic errors (Landrigan et al., 2004). The same physicians, the same case, a different time of day, and the judgement comes out differently. Judgement quality is not a stable personal trait but a function of person and context.
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Croskerry, P. (2002). Achieving Quality in Clinical Decision Making: Cognitive Strategies and Detection of Bias. Academic Emergency Medicine, 9(11), 1184–1204. https://doi.org/10.1197/aemj.9.11.1184
Croskerry, P. (2003a). Cognitive forcing strategies in clinical decisionmaking. Annals of Emergency Medicine, 41(1), 110–120. https://doi.org/10.1067/mem.2003.22
Croskerry, P. (2003b). The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them: Academic Medicine, 78(8), 775–780. https://doi.org/10.1097/00001888-200308000-00003
Croskerry, P. (2009). A Universal Model of Diagnostic Reasoning: Academic Medicine, 84(8), 1022–1028. https://doi.org/10.1097/ACM.0b013e3181ace703
Croskerry, P. (2013). From Mindless to Mindful Practice—Cognitive Bias and Clinical Decision Making. New England Journal of Medicine, 368(26), 2445–2448. https://doi.org/10.1056/NEJMp1303712
Croskerry, P., Singhal, G., & Mamede, S. (2013). Cognitive debiasing 1: Origins of bias and theory of debiasing. BMJ Quality & Safety, 22(Suppl 2), ii58–ii64. https://doi.org/10.1136/bmjqs-2012-001712
Elmore, J. G., Jackson, S. L., Abraham, L., Miglioretti, D. L., Carney, P. A., Geller, B. M., Yankaskas, B. C., Kerlikowske, K., Onega, T., Rosenberg, R. D., Sickles, E. A., & Buist, D. S. M. (2009). Variability in Interpretive Performance at Screening Mammography and Radiologists’ Characteristics Associated with Accuracy. Radiology, 253(3), 641–651. https://doi.org/10.1148/radiol.2533082308
Elmore, J. G., Wells, C. K., Lee, C. H., Howard, D. H., & Feinstein, A. R. (1994). Variability in Radiologists’ Interpretations of Mammograms. New England Journal of Medicine, 331(22), 1493–1499. https://doi.org/10.1056/NEJM199412013312206
Graber, M. L., Franklin, N., & Gordon, R. (2005). Diagnostic Error in Internal Medicine. Archives of Internal Medicine, 165(13), 1493. https://doi.org/10.1001/archinte.165.13.1493
Kunitomo, K., Harada, T., & Watari, T. (2022). Cognitive biases encountered by physicians in the emergency room. BMC Emergency Medicine, 22(1), 148. https://doi.org/10.1186/s12873-022-00708-3
Landrigan, C. P., Rothschild, J. M., Cronin, J. W., Kaushal, R., Burdick, E., Katz, J. T., Lilly, C. M., Stone, P. H., Lockley, S. W., Bates, D. W., & Czeisler, C. A. (2004). Effect of Reducing Interns’ Work Hours on Serious Medical Errors in Intensive Care Units. New England Journal of Medicine, 351(18), 1838–1848. https://doi.org/10.1056/NEJMoa041406
Norman, G. R., Monteiro, S. D., Sherbino, J., Ilgen, J. S., Schmidt, H. G., & Mamede, S. (2017). The Causes of Errors in Clinical Reasoning: Cognitive Biases, Knowledge Deficits, and Dual Process Thinking. Academic Medicine, 92(1), 23–30. https://doi.org/10.1097/ACM.0000000000001421
How I work
I do not intervene in clinical processes or supplement medical expertise. I work where expertise is in place but systematic judgement traps are undermining decision quality.
To do that, I make cognitive biases and judgement variability tangible within the clinical context, drawing on real cases and research findings. From there, we develop together the structural consequences: checkpoints, handover standards and reflection formats that work in everyday clinical practice.
Short formats
A 20-minute input for internal training or professional events
A 30 to 60-minute keynote, with or without Q&A
Both formats are suited to opening up a topic that many recognise but rarely approach in a structured way.
Workshops
90 to 180 minutes, interactive and case-based
Suited to clinical teams who want to identify and work through specific patterns in their own practice.
Advisory
Facilitated clarification sessions for leadership teams, as well as ongoing advisory work for quality assurance and error culture
The focus here is not on one-off awareness-raising but on structural changes to the judgement process.
Who this is for
This work is for clinical directors and chief physicians who want to treat error culture and decision quality not merely as a matter of attitude but as a structural question,
for those responsible for quality management who want to make judgement variability within their teams visible,
and for leadership teams in hospitals and medical institutions who want to design handover and coordination processes so that judgement quality does not depend on chance.
What all of them share is the question of why competent people still judge poorly.
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