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.

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.

A Patient With Oral Discomfort and Reduced Oral Aperture.

A patient had burning and pain in the mouth, reduced oral aperture, white-tan plaques on the oral mucosa, and thickened buccal mucosae bilaterally; biopsy of the lower labial mucosa showed subepithelial fibrosis. She had no history of cigarette smoking or use of chewing tobacco but had current and past history of chewing areca nuts. What is the diagnosis and what would you do next?

Comorbid psychiatric disease significantly mediates increased rates of alcohol use disorder among patients with inflammatory and pigmentary skin disorders: a case-control study in the All of Us Research Program.

Dermatologic diseases have a well-documented association with depression and anxiety, which are in turn often comorbid with alcohol use disorder (AUD). Nonethleess, the relationship between dermatologic disease and AUD, and the relative contribution of depression and anxiety, are poorly understood. Here, we utilize the National Insittutes of Health All of Us Research Program to investigate the association between inflammatory and pigmentary dermatologic diseases with AUD. Furthermore, we investigate whether comorbid depression and anxiety mediates this relationship. We employed a matched case-control model with multivariable logistic regression. We also employed a mediation analysis. We found an increased odds of AUD among patients with atopic dermatitis, acne/rosacea, hidradenitis suppurativa, psoriasis, and pigmentary disorders (vitiligo, melasma, and post-inflammatory hyperpigmentation). This was partially mediated by anxiety and depression, especially for diseases with a significant cosmetic component. Overall, these findings highlight the profound psychological and physical health effects that inflammatory and pigmentary disease can have on patients, both independently and in combination with comorbid psychiatric disease.

Racial and Ethnic Differences Among Adult Patients Hospitalized for Skin and Soft Tissue Infection: A Cross-Sectional Analysis of 2012-2017 New York State Data.

Skin and soft tissue infections (SSTI) can result in hospitalizations and lead to increased healthcare costs and morbidity. Racial and ethnic disparities in healthcare access, utilization, and outcomes are well-documented. However, limited studies exist on racial and ethnic differences among adult patients hospitalized for SSTI. Our study utilized a large dataset from New York State to investigate such differences. Findings suggest that racial and ethnic minority patients hospitalized for SSTI are younger, primarily covered by Medicaid, and have a higher cost of hospitalization compared to White patients, even after controlling for length of stay and severity of illness. Possible explanations for these disparities include differences in comorbidities and structural vulnerabilities. Further studies are needed to elucidate potential causes of these disparities and their impact on clinical outcomes.

Barriers to Care Among Sexual and Gender Minority Individuals With Chronic Inflammatory Skin Diseases in the US.

Importance: Research on the prevalence of barriers to care among sexual and gender minority (SGM) patients with chronic inflammatory skin diseases (CISDs) in the US is limited. Objective: To compare the prevalence of cost and noncost barriers to care among SGM and non-SGM patients with CISDs and to analyze the prevalence of barriers based on SGM status and race and ethnicity. Design, Setting, and Participants: A cross-sectional study of health care access and utilization survey data collected by the National Institutes of Health's All of Us Research Program between May 31, 2017, and July 1, 2022, was conducted. Participants were adults aged 18 years or older with CISDs who enrolled in All of Us directly online or through partner health care practitioner organizations located across the US. Exposures: Chronic inflammatory skin diseases, sexual orientation and gender identity, and race and ethnicity. Main Outcome and Measures: The main outcome was the experience of cost and noncost barriers to health care among SGM patients with CISDs. Multivariable logistic regression was used to examine the association of SGM status with experiencing barriers to care. Results: This study included 19 743 patients with CISDs; 1877 were SGM patients (median age, 40.5 years [IQR, 28.7-57.9 years]; 1205 [64.2%] assigned female sex at birth) and 17 866 were non-SGM patients (median age, 57.1 years [IQR, 40.8-68.1 years]; 13 205 [73.9%] assigned female sex at birth). Compared with non-SGM patients, SGM patients with CISDs were significantly more likely to delay specialist care (adjusted odds ratio [AOR], 1.23; 95% CI, 1.03-1.47), mental health care (AOR, 1.62; 95% CI, 1.37-1.91), and filling a prescription (AOR, 1.30; 95% CI, 1.11-1.52) because of cost. In addition, SGM patients with CISDs were significantly more likely than non-SGM patients to delay care because of transportation issues (AOR, 1.49; 95% CI, 1.22-1.80) and not having a health care practitioner who shares the same background with regard to race and ethnicity, religion, native language, sexual orientation, and gender identity (AOR, 1.39; 95% CI, 1.19-1.62). Sexual and gender minority patients with CISDs were also significantly more likely than non-SGM patients to report not always being treated with respect by their health care practitioners (AOR, 1.47; 95% CI, 1.30-1.65). Conclusions and Relevance: The findings of this cross-sectional study of survey data suggest that SGM patients with CISDs may be disproportionately affected by cost and noncost barriers to health care. Dermatologists and other health care practitioners caring for SGM patients with CISDs have an important role in helping to address these barriers and larger systemic issues for SGM patients at both the patient and system levels.