Are Pathologists Self-Aware of Their Diagnostic Accuracy? Metacognition and the Diagnostic Process in Pathology

Background Metacognition is a cognitive process that involves self-awareness of thinking, understanding, and performance. This study assesses pathologists’ metacognition by examining the association between their diagnostic accuracy and self-reported confidence levels while interpreting skin and breast biopsies. Design We studied 187 pathologists from the Melanoma Pathology Study (M-Path) and 115 pathologists from the Breast Pathology Study (B-Path). We measured pathologists’ metacognitive ability by examining the area under the curve (AUC), the area under each pathologist’s receiver operating characteristic (ROC) curve summarizing the association between confidence and diagnostic accuracy. We investigated possible relationships between this AUC measure, referred to as metacognitive sensitivity, and pathologist attributes. We also assessed whether higher metacognitive sensitivity affected the association between diagnostic accuracy and a secondary diagnostic action such as requesting a second opinion. Results We found no significant associations between pathologist clinical attributes and metacognitive AUC. However, we found that pathologists with higher AUC showed a stronger trend to request secondary diagnostic action for inaccurate diagnoses and not for accurate diagnoses compared with pathologists with lower AUC. Limitations Pathologists reported confidence in specific diagnostic terms, rather than the broader classes into which the diagnostic terms were later grouped to determine accuracy. In addition, while there is no gold standard for the correct diagnosis to determine the accuracy of pathologists’ interpretations, our studies achieved a high-quality reference diagnosis by using the consensus diagnosis of 3 experienced pathologists. Conclusions Metacognition can affect clinical decisions. If pathologists have self-awareness that their diagnosis may be inaccurate, they can request additional tests or second opinions, providing the opportunity to correct inaccurate diagnoses. Highlights Metacognitive sensitivity varied across pathologists, with most showing higher sensitivity than expected by chance. None of the demographic or clinical characteristics we examined was significantly associated with metacognitive sensitivity. Pathologists with higher metacognitive sensitivity were more likely to request additional tests or second opinions for their inaccurate diagnoses.