Perception of the usability and implementation of a metacognitive mnemonic to check cognitive errors in clinical setting

Keng Chew, Jeroen van Merrienboer, Steven Durning

Research output: Contribution to journalArticlepeer-review

4 Citations (Scopus)
18 Downloads (Pure)


Background: Establishing a diagnosis is a complex, iterative process involving patient data gathering, integration and interpretation. Premature closure is a fallacious cognitive tendency of closing the diagnostic process before sufficient data have been gathered. A proposed strategy to minimize premature closure is the use of a checklist to trigger metacognition (the process of monitoring one's own thinking). A number of studies have suggested the effectiveness of this strategy in classroom settings. This qualitative study examined the perception of usability of a metacognitive mnemonic checklist called TWED checklist (where the letter "T = Threat", "W = What if I am wrong? What else?", "E = Evidence" and "D = Dispositional influence") in a real clinical setting. Method: Two categories of participants, i.e., medical doctors (n = 11) and final year medical students (Group 1, n = 5; Group 2, n = 10) participated in four separate focus group discussions. Nielsen's 5 dimensions of usability (i.e. learnability, effectiveness, memorability, errors, and satisfaction) and Pentland's narrative network were adapted as the framework to study the usability and the implementation of the checklist in a real clinical setting respectively. Results: Both categories (medical doctors and medical students) of participants found that the TWED checklist was easy to learn and effective in promoting metacognition. For medical student participants, items "T" and "W" were believed to be the two most useful aspects of the checklist, whereas for the doctor participants, it was item "D". Regarding its implementation, item "T" was applied iteratively, items "W" and "E" were applied when the outcomes did not turn out as expected, and item "D" was applied infrequently. The one checkpoint where all four items were applied was after the initial history taking and physical examination had been performed to generate the initial clinical impression. Conclusion: A metacognitive checklist aimed to check cognitive errors may be a useful tool that can be implemented in the real clinical setting.

Original languageEnglish
Article number18
JournalBMC Medical Education
Issue number1
Publication statusPublished - 10 Jan 2019

Bibliographical note

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License CC BY (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.


  • Cognitive errors
  • clinical decision making
  • Mnemonic
  • Checklist
  • Usability
  • implementation
  • Clinical decision making
  • Implementation


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