Reflecting on Cognitive Error

Published on Nov 19, 2015

A graphic guide for clinical educators to encourage medical students to engage in reflective thinking, especially with respect to possible cognitive error, before, during and after patient encounters. Author: Karen Spear Ellinwood, PhD, JD, EdS, Director, Faculty Instructional Development, Residents as Educators Program; Assistant Professor, Department of Obstetrics and Gynecology, University of Arizona College of Medicine.


Cultivate a Habit of Reflection:

Looking for Cognitive Error
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If you agree that...

"Anyone who has never made a mistake has never tried anything new."

- Albert Einstein (1879-1955)

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"I believe in being a reflective practitioner — learning from our mistakes by a process of reflection, both personally and with others."

Charlotte Elder
Clinical lecturer in Paediatrics, University of Sheffield, BMJ Blogs

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Reflective educators "facilitate reflective observation, encourage conceptual thinking, and provide feedback and testing of insights drawn
from the experience"

(Ryan 2010, 117).

Then, advise your students ...

"Reflection is particularly important in medicine" where physicians are required to "analyze best evidence while considering his or her values and assumptions vis-à-vis the values, beliefs, and goals of each patient."

Plack & Greenberg (2005, 1547)

"Train for a reflective approach to problem solving: stepping back from the immediate problem to examine and reflect on the thinking process."
- Croskerry (2003, 779)

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Patients appreciate

when you get it right!
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Reflect BEFORE

clinical experiences

Cognitive Error

Prevent it when possible - Reflect on it first
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Safety First

prevent cognitive error
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Know your Limitations

prevent cognitive error

Rethink it

before you try it

Reflect DURING

Clinical Experiences

Reflect & Rethink

as you collect and process information

Reflect AFTER

Clinical Experiences


Did I make an error?
Could I have avoided it?
Could I avoid it next time?
How could I improve my approach?

Cognitive Debiasing Strategies

(Croskerry 03)

Provide adequate time for quality decision-making

Ask students to consider alternative possibilities

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Provide guidance for learning clinical knowledge

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Help students develop awareness & insight

Remind your students

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You're not alone

Ask for help - Ask for feedback
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Remind yourself

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You're not alone

Ask Colleagues for Ideas on Giving Feedback


  • Croskerry P. Cognitive Forcing Strategies in Clinical Decisionmaking. Annals of Emergency Medicine 41(1): 110-20; 2003.


  • Plack MM & Greenberg L. The Reflective Practitioner: Reaching for Excellence in Practice. Pediatrics 116: 1546-52; 2005.


  • Ryan CA. Refective Inquiry in the Medical Profession. In, Handbook of Reflection and Reflective Inquiry: Mapping a Way of Knowing for Professional Reflective Inquiry. Springer, 101-130; 2010.

Karen Spear Ellinwood, PhD, JD

Director, Faculty Instructional Development
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