Cognitive Bias in the Patient Encounter: Part I. Background and significance.

Cognitive bias may lead to diagnostic error in the patient encounter. There are hundreds of different cognitive biases, but certain biases are more likely to affect patient diagnosis and management. As during morbidity and mortality rounds, retrospective evaluation of a given case, with comparison to an optimal diagnosis, can pinpoint errors in judgment and decision-making. The study of cognitive bias also illuminates how we might improve the diagnostic process. In Part 1 of this series, cognitive bias is defined and placed within the background of dual process theory, emotion, heuristics, and the more neutral term judgment and decision-making bias.

Cognitive Bias in the Patient Encounter: Part II. Debiasing using an adaptive toolbox.

Cognitive bias may lead to medical error, and awareness of cognitive pitfalls is a potential first step to addressing the negative consequences of cognitive bias (see Part 1). For decision-making processes that occur under uncertainty, which encompass most physician decisions, a so-called "adaptive toolbox" is beneficial for good decisions. The adaptive toolbox is inclusive of broad strategies like cultural humility, emotional intelligence, and self-care that help combat implicit bias, negative consequences of affective bias, and optimize cognition. Additionally, the adaptive toolbox includes situational-specific tools such as heuristics, narratives, cognitive forcing functions, and fast and frugal trees. Such tools may mitigate against errors due to cultural, affective, and cognitive bias. Part 2 of this two-part series covers metacognition and cognitive bias in relation to broad and specific strategies aimed at better decision-making.

Adaptive expertise in medical decision making.

AIM: Recently, a growing awareness has developed of the extraordinary complexity of factors that influence the clinical reasoning underpinning the diagnostic process. The aim of the present report is to delineate these factors and suggest strategies for dealing more effectively with this complexity. METHOD: Six major clusters of factors are described here: (A) individual characteristics of the decision maker, (B) individual intellectual and cognitive styles, (C) ambient and homeostatic factors, (D) factors in the work environment including team factors, (E) characteristics of the medical condition, and (F) factors associated with the patient. Additional factors, such as health care systems, culture, politics, and others are also important. RESULTS: A review of the literature suggests that most clinicians trained under existing methods achieve a level of expertise presently referred to as "routine" or "classic." The results of studies of diagnostic failure, however, suggest that this level of expertise has proved insufficient. A growing literature suggests that more effective clinical decision might be achieved through adaptive reasoning, leading to enhanced levels of expertise and mastery. CONCLUSIONS: It is proposed here that adaptive expertise may be achieved through emphasizing additional features of the reasoning process: being aware of the inhibitors and facilitators of rationality; pursuing the standards of critical thinking; developing a comprehensive awareness of cognitive and affective biases and how to mitigate them; developing a similar depth and understanding of logic and its fallacies; engaging metacognitive processes such as reflection and mindfulness; and through approaches embracing creativity, lateral thinking, and innovation.

Cognitive bias in health leaders.

Cognitive bias can be a serious impediment to rational decision-making by health leaders. We use a hypothetical case study to introduce some basic concepts of bias with examples of mitigation strategies. We argue that the effect of biases should be considered when making every significant administrative decision.

The challenge of cognitive science for medical diagnosis.

The historical tendency to view medicine as both an art and a science may have contributed to a disinclination among clinicians towards cognitive science. In particular, this has had an impact on the approach towards the diagnostic process which is a barometer of clinical decision-making behaviour and is increasingly seen as a yardstick of clinician calibration and performance. The process itself is more complicated and complex than was previously imagined, with multiple variables that are difficult to predict, are interactive, and show nonlinearity. They appear to characterise a complex adaptive system. Many aspects of the diagnostic process, including the psychophysics of signal detection and discrimination, ergonomics, probability theory, decision analysis, factor analysis, causal analysis and more recent developments in judgement and decision-making (JDM), especially including the domain of heuristics and cognitive and affective biases, appear fundamental to a good understanding of it. A preliminary analysis of factors such as manifestness of illness and others that may impede clinicians' awareness and understanding of these issues is proposed here. It seems essential that medical trainees be explicitly and systematically exposed to specific areas of cognitive science during the undergraduate curriculum, and learn to incorporate them into clinical reasoning and decision-making. Importantly, this understanding is needed for the development of cognitive bias mitigation and improved calibration of JDM in clinical practice.

Evidence and its uses in health care and research: the role of critical thinking.

Obtaining and critically appraising evidence is clearly not enough to make better decisions in clinical care. The evidence should be linked to the clinician's expertise, the patient's individual circumstances (including values and preferences), and clinical context and settings. We propose critical thinking and decision-making as the tools for making that link. Critical thinking is also called for in medical research and medical writing, especially where pre-canned methodologies are not enough. It is also involved in our exchanges of ideas at floor rounds, grand rounds and case discussions; our communications with patients and lay stakeholders in health care; and our writing of research papers, grant applications and grant reviews. Critical thinking is a learned process which benefits from teaching and guided practice like any discipline in health sciences. Training in critical thinking should be a part or a pre-requisite of the medical curriculum.

Narrowing the mindware gap in medicine.

Medical error is now recognized as one of the leading causes of death in the United States. Of the medical errors, diagnostic failure appears to be the dominant contributor, failing in a significant number of cases, and associated with a high degree of morbidity and mortality. One of the significant contributors to diagnostic failure is the cognitive performance of the provider, how they think and decide about the process of diagnosis. This thinking deficit in clinical reasoning, referred to as a mindware gap, deserves the attention of medical educators. A variety of specific approaches are outlined here that have the potential to close the gap.

Correction: A Cognitive Autopsy Approach Towards Explaining Diagnostic Failure.

[This corrects the article DOI: 10.7759/cureus.17041.].

A Cognitive Autopsy Approach Towards Explaining Diagnostic Failure.

Diagnostic failure has emerged as one of the most significant threats to patient safety. It is important to understand the antecedents of such failures both for clinicians in practice as well is those in training. A consensus has developed in the literature that the majority of failures are due to individual or system factors or some combination of the two. A major source of variance in individual clinical performance is cognitive and affective biases; however, their role in clinical decision making has been difficult to assess partly because they are difficult to investigate experimentally. A significant drawback has been that experimental manipulations appear to confound the assessment of the context surrounding the diagnostic process itself. We conducted an exercise on selected actual cases of diagnostic errors to explore the effect of biases in the 'real world' emergency medicine (EM) context. Thirty anonymized EM cases were analysed in depth through a process of root cause analysis that included an assessment of error-producing conditions (EPCs), knowledge-based errors, and how clinicians were thinking and deciding during each case. A prominent feature of the exercise was the identification of the occurrence of and interaction between specific cognitive and affective biases, through a process called cognitive autopsy. The cases covered a broad range of diagnoses across a wide variety of disciplines. A total of 24 discrete cognitive and affective biases that contributed to misdiagnosis were identified and their incidence recorded. Five to six biases were detected per case, and observed on 168 occasions across the 30 cases. Thirteen EPCs were identified. Knowledge-based errors were rare, occurring in only five definite instances. The ordinal position in which biases appeared in the diagnostic process was recorded. This experiment provides a baseline for investigating and understanding the critical role that biases play in clinical decision making as well as providing a credible explanation for why diagnoses fail.

Clinical cognition and diagnostic error: applications of a dual process model of reasoning.

Both systemic and individual factors contribute to missed or delayed diagnoses. Among the multiple factors that impact clinical performance of the individual, the caliber of cognition is perhaps the most relevant and deserves our attention and understanding. In the last few decades, cognitive psychologists have gained substantial insights into the processes that underlie cognition, and a new, universal model of reasoning and decision making has emerged, Dual Process Theory. The theory has immediate application to medical decision making and provides an overall schema for understanding the variety of theoretical approaches that have been taken in the past. The model has important practical applications for decision making across the multiple domains of healthcare, and may be used as a template for teaching decision theory, as well as a platform for future research. Importantly, specific operating characteristics of the model explain how diagnostic failure occurs.

Paramedic clinical decision making during high acuity emergency calls: design and methodology of a Delphi study.

BACKGROUND: The scope of practice of paramedics in Canada has steadily evolved to include increasingly complex interventions in the prehospital setting, which likely have repercussions on clinical outcome and patient safety. Clinical decision making has been evaluated in several health professions, but there is a paucity of work in this area on paramedics. This study will utilize the Delphi technique to establish consensus on the most important instances of paramedic clinical decision making during high acuity emergency calls, as they relate to clinical outcome and patient safety. METHODS AND DESIGN: Participants in this multi-round survey study will be paramedic leaders and emergency medical services medical directors/physicians from across Canada. In the first round, participants will identify instances of clinical decision making they feel are important for patient outcome and safety. On the second round, the panel will rank each instance of clinical decision making in terms of its importance. On the third and potentially fourth round, participants will have the opportunity to revise the ranking they assigned to each instance of clinical decision making. Consensus will be considered achieved for the most important instances if 80% of the panel ranks it as important or extremely important. The most important instances of clinical decision making will be plotted on a process analysis map. DISCUSSION: The process analysis map that results from this Delphi study will enable the gaps in research, knowledge and practice to be identified.

Context is everything or how could I have been that stupid?

Dual Process Theory provides a useful working model of decision-making. It broadly divides decision-making into intuitive (System 1) and analytical (System 2) processes. System 1 is especially dependent on contextual cues. There appears to be a universal human tendency to contextualize information, mostly in an effort to imbue meaning but also, perhaps, to conserve cognitive energy. Most decision errors occur in System 1, and this has two major implications. The first is that insufficient account may have been taken out of context when the original decision was made. Secondly, in trying to learn from decision failures, we need the highest fidelity of context reconstruction as possible. It should be appreciated that learning from past events is inevitably an imperfect process. Retrospective investigations, such as root-cause analysis, critical incident review, morbidity and mortality rounds and legal investigations, all suffer the limitation that they cannot faithfully reconstruct the context in which decisions were made and from which actions followed.

Competencies for improving diagnosis: an interprofessional framework for education and training in health care.

Background Given an unacceptably high incidence of diagnostic errors, we sought to identify the key competencies that should be considered for inclusion in health professions education programs to improve the quality and safety of diagnosis in clinical practice. Methods An interprofessional group reviewed existing competency expectations for multiple health professions, and conducted a search that explored quality, safety, and competency in diagnosis. An iterative series of group discussions and concept prioritization was used to derive a final set of competencies. Results Twelve competencies were identified: Six of these are individual competencies: The first four (#1-#4) focus on acquiring the key information needed for diagnosis and formulating an appropriate, prioritized differential diagnosis; individual competency #5 is taking advantage of second opinions, decision support, and checklists; and #6 is using reflection and critical thinking to improve diagnostic performance. Three competencies focus on teamwork: Involving the patient and family (#1) and all relevant health professionals (#2) in the diagnostic process; and (#3) ensuring safe transitions of care and handoffs, and "closing the loop" on test result communication. The final three competencies emphasize system-related aspects of care: (#1) Understanding how human-factor elements influence the diagnostic process; (#2) developing a supportive culture; and (#3) reporting and disclosing diagnostic errors that are recognized, and learning from both successful diagnosis and from diagnostic errors. Conclusions These newly defined competencies are relevant to all health professions education programs and should be incorporated into educational programs.