Volume 52, Issue 9, September 2023


Brendon Evans   
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Breathing: Deliberate thinking – Avoiding medical errors

Expect the unexpected, or you won’t find it.

– Heraclitus1

De Bono’s paradigm of the ‘six thinking hats’2 – first published in 1985 – is a highly impactful cognitive framework applied widely in business, psychology and educational fields.3 It guides the thinker to view a problem from differing perspectives; for example, ‘white hat’ thinking examines the facts and data about the problem, and ‘red hat’ thinking explores the feelings and emotions of those involved with – and potentially affected by – the decision. The other points of view are equally important: the ‘green hat’ for innovation, opportunity and alternatives; ‘black hat’ for addressing risk, difficulties and problems; ‘yellow hat’ for positivity and upside; and ‘blue hat’ for overarching structure and managing the thinking process. Each ‘hat’ represents an important way of viewing the problem that might be missed if not explicitly called upon. This process also deliberately slows down the cognitive process to avoid quick, less-informed decisions. By explicitly addressing these differing points of view, the model works towards ensuring opportunities are identified and risks avoided.

Missed diagnosis is a significant problem in both general practice and the wider medical profession. It is estimated that 140,000 diagnostic errors occur annually, with 21,000 cases of serious harm and 4000 deaths across the entire Australian medical field.4 Furthermore, the most common category of litigation against Australian general practitioners is alleged missed diagnosis.5 Surely, all would agree that each error causing harm is a tragedy that should be avoided whenever possible?

The very nature of some presentations can lead the unwary practitioner into pitfalls. Papers within this issue illustrate emerging evidence of urological complications of obstructive sleep apnoea (OSA)6 and of insomnia being co-morbidly present with OSA7 – unexpected twists from common conditions. Systematic approaches might promote timely, correct and complete diagnosis, and the reduction of mistakes.8

Fortunately, general practice has a long history of advocating for a systematic approach similar to de Bono’s to reasoning through complex medical presentations. Former Editor-in-Chief of this Journal, Professor John Murtagh, has taught for decades to deliberately separate medical thinking into differing points of view.9 His method consists of first considering the ‘probability diagnosis’, then systematically addressing: ‘serious disorders not to be missed’; ‘pitfalls’, or commonly missed conditions; ‘masquerading’ conditions that can present in many different forms; and remembering to consider mental health by asking ‘is the patient trying to tell me something’. This deliberate consideration of what might be otherwise unexpected is an outstanding failsafe to minimise misdiagnosis.

As a medical educator, each year I wonder why so many registrars have not heard of this potentially life-saving framework after both medical school and residency. Explicit, focussed, and repeated teaching of clinical reasoning10 and the systematic diagnostic approach is needed to produce high-quality RACGP Fellows. Furthermore, consistent career-long consideration and application of these principles is the mark of an excellent general practitioner.

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  2. De Bono E. Six thinking hats: The multi-million bestselling guide to running better meetings and making faster decisions. Penguin Life, 2017. Search PubMed
  3. The de Bono Group. Six thinking hats. De Bono Group, (n.d.). Available at [Accessed 9 June 2023]. Search PubMed
  4. Sax Institute. Knowledge lacking on scale of diagnostic error problem. Sax Institute, 2013. Available at [Accessed 9 June 2023]. Search PubMed
  5. Bird S. Diagnostic tests and litigation. Aust Prescr 2012;35(4):107. doi: 10.18773/austprescr.2012.045 Search PubMed
  6. Hurlbert M, Yao J, Femia G. Urological manifestations of obstructive sleep apnoea and their clinical utility in screening. Aust J Gen Pract 2023;52(9): 599–604. Search PubMed
  7. Sweetman A, Frank O, Stocks N, Mukherjee S, Lack L. General practitioner management of comorbid insomnia and sleep apnoea. Aust J Gen Pract 2023;52(9): 607–12. Search PubMed
  8. Dave N, Bui S, Morgan C, Hickey S, Paul CL. Interventions targeted at reducing diagnostic error: Systematic review. BMJ Qual Saf 2022;31(4):297–307. doi: 10.1136/bmjqs-2020-012704. Search PubMed
  9. Murtagh J, Rosenblatt J, Murtagh C, Coleman J. Murtagh general practice. 8th edn. McGraw Hill, 2023. Search PubMed
  10. Scott IA, Crock C. Diagnostic error: Incidence, impacts, causes and preventive strategies. Med J Aust 2020;213(7):302–305.e2. doi: 10.5694/mja2.50771. Search PubMed

Clinical reasoningEditorialGeneral practiceSystematic diagnostic approach

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