Avoiding thinking errors in neuro-ophthalmic clinical diagnosis

This editorial presents the cases of three patients with multiple diagnoses that highlight the importance of avoiding thinking errors in neuro-ophthalmic clinical decision-making. The cases demonstrate that the most obvious diagnosis may not be the most important.

The author reminds ophthalmologists of the importance of Hickam's dictum, which says that patients can have many illnesses and we cannot always ascribe the patient’s condition to one disease. This is the counter-argument to Occam's razor, which implies that the simplest diagnosis is usually the best.

I am personally fond of a quote by Sherlock Holmes stating, "When you have eliminated the impossible, whatever remains, however improbable, must be the truth.”

Each patient had two important diseases, one of which was more obvious, but not necessarily more significant, than the other. The author notes that differentiating patients who conform to Occam’s razor from those who fulfill Hickam’s dictum can be challenging and subject to cognitive bias.

He continues that although intuitive thinking is highly effective and essential to our daily decision-making, it is in this mode that most biases and other cognitive failures occur. He suggests that a blend of intuitive and analytical thinking might provide the best foundation for optimal decision-making in neuro-ophthalmology.

He also discusses the importance of avoiding cognitive biases that affect clinical decision-making. These include anchoring, availability, confirmation, framing, unpacking and premature closure, which he discusses in more detail.