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I would like to congratulate Chew et al on their novel checklist to improve metacognition and reduce errors in clinical decision-making.(1) This thoughtful and explicit approach is feasible and has great potential. Acronyms as mnemonic devices can work better when they are orthographically correct and aesthetically satisfying.(2) I would recommend using ‘WELD’ instead of ‘TWED’ (T = threat to life or limb, W = what else, E = evidence and D = dispositional factors). The parameters remain the same: W = what else/what else could it be/what if I am wrong, E = evidence – is it sufficient to conclude or exclude a diagnosis, L = life-or-limb threat (worst-case scenario) and D = dispositional factors – what emotional and environmental dispositions may be influencing my decisions. The use of Chew et al’s checklist tool should certainly help ‘WELD’ the importance of careful reflection into physicians’ minds and, in turn, help us ‘WELD’ the correct diagnosis and improve patient outcomes.
1. Chew KS, Durning SJ, van Merriënboer JJ. Teaching metacognition in clinical decision-making using a novel mnemonic checklist: an exploratory study. Singapore Med J 2016; 57:694-700.
2. Pottegård A, Haastrup MB, Stage TB, et al. SearCh for humourIstic and Extravagant acroNyms and Thoroughly Inappropriate names For Important Clinical trials (SCIENTIFIC): qualitative and quantitative systematic study. BMJ 2014 Dec 16;349:g7092.