Authors’ reply: Comment on: Teaching metacognition in clinical decision-making using a novel mnemonic checklist: an exploratory study

Dear Sir,

We would like to thank Kelly(1) for the suggestion of using ‘WELD’ instead of ‘TWED’ as the mnemonic structure for our checklist(2) to improve metacognition in clinical decision-making. While we agree that ‘WELD’ certainly appears more orthographically correct and aesthetically satisfying, an important consideration when designing our checklist was to prioritise the parameters. A useful checklist should not only be straightforward and focused enough to be used seamlessly (e.g. giving it high portability), but its contents should also be prioritised in accordance with the purpose for which the checklist was designed.(3) As the overarching purpose of this checklist is to minimise cognitive errors, we placed the letter ‘T’ first, as checking for any potentially fatal disease processes(4) should be the physician’s top priority, particularly in the context of a busy clinical setting.

Finally, as the meaning of ‘weld’, according to the Merriam-Webster dictionary, is “to unite (metallic parts) by heating and allowing the metals to flow together”, the word imagery might connote cementing a diagnosis to the point of closing the mind to any other possibilities, which is tantamount to committing cognitive errors such as premature closure or gaining diagnostic momentum. We prefer the word imagery of ‘TWED’, which brings to mind the word ‘tweed’, a fabric that is the result of weaving together multiple colors and/or textures; this connotation is closer to the flexibility needed in clinical practice. While we are certainly open to suggestions on the mnemonic structure of this checklist, aesthetic modification(s) should not potentially compromise the very foundation on which this checklist was built.

Yours sincerely,