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This supplement to The American Journal of Medicine centers on the widely acknowledged occurrence of frequent errors in medical practice, especially in medical diagnosis. In the featured article, Drs. Eta S. Berner and Mark L. Graber bring our attention directly to the paucity of penitents among the crowd of seemingly unaware sinners. They convincingly demonstrate that we physicians lack strong direct and timely feedback about our decisions. Given that most medical decisions, however curious our reasoning, actually work relatively well within our chosen practice situation, we are not acutely anxious about oversights. In other words, the average day does not confront us with our errors.

Drs. Berner and Graber summarize an extensive body of scholarly writing about teaching, learning, reasoning, and decision making as it relates to diagnostic error and overconfidence, which is expanded upon by their colleagues. In the first commentary, Drs. Pat Croskerry and Geoff Norman review 2 modes of clinical reasoning in an effort to better understand the processes underlying overconfidence. Ms. Beth Crandall and Dr. Robert L. Wears highlight gaps in knowledge about the nature of diagnostic problems, emphasizing the limitations of applying static models to the messy world of clinical practice. Clearly, many experts are concerned about these processes. I commend this volume to any professional or lay reader who thinks it is easy to bring medical decision making closer to the ideal.

One finds a theme repeating in these carefully reasoned papers: namely, that, as phrased by Dr. Gordon L. Schiff in the fourth commentary, “Learning and feedback are inseparable.” This issue is addressed from a variety of perspectives. In the third commentary, Drs. Jenny W. Rudolph and J. Bradley Morrison provide an expanded model of the fundamental feedback processes involved in diagnostic problem solving, highlighting particular leverage points for avoiding error. Dr. Schiff explicates the numerous barriers to adequate feedback and follow-up in the real world of clinical practice and emphasizes the need for a systematic tracking approach over time that fully involves patients. In the final commentary, Dr. Graber identifies stakeholders interested in medical diagnosis and provides recommendations to help each reduce diagnostic error.

These papers sound a second theme, also worth noting. That is, medical practitioners really do not use systems designed to aid their diagnostic decision making. The exception is the case already recognized to be miserably complex or misdiagnosed! This fits my own experience. In the 1980s, I developed a system to aid medical reasoning called CONSIDER. Its purpose was to increase the likelihood that the correct diagnosis appeared on the list of differential diagnoses considered by the physician. Although surprisingly apt (and offered free of charge by Missouri Regional Medical Program), the system produced many astonishing and, at times, amusing anecdotal reports, particularly regarding “tough” cases, but no rush to employment or major changes in mortality rates.

Consequently, I sympathize with and respectfully salute these present efforts to study diagnostic decision making and to remedy its weaknesses. In closing, I applaud especially the suggestions to systematize the incorporation of the “downstream” experiences and participation of the patients in all efforts to improve the diagnostic process. These problems likely will not get better until the average day does confront us with our errors.

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Author disclosures 

Donald A.B. Lindberg, MD, has no financial arrangement or affiliation with a corporate organization or a manufacturer of a product discussed in this article.