Do you know if your assessments are biased? Cognitive biases and heuristics may affect musculoskeletal assessment and clinical decision-making

Abstract Heuristics and cognitive biases constantly influence clinical decision-making and often facilitate judgements under uncertainty. They can frequently, however, lead to diagnostic errors and adverse outcomes, particularly when considering rare disease processes that have common, masquerading presentations. Herein, we present two such cases of newborn infants with hypertensive renal disorders that were initially thought to have cardiomyopathy.

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A foreign older diabetic woman with an acute myocardial infarction: when cognitive biases in clinical decision-making become especially important

BMJ Case Reports ◽

10.1136/bcr-2017-223135 ◽

2018 ◽

pp. bcr-2017-223135 ◽

Cited By ~ 1

Author(s):

Mathias Schlögl ◽

Daniel Hofmänner ◽

Robert Manka ◽

Dagmar I Keller

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Decision Making ◽

Clinical Decision Making ◽

Cognitive Biases ◽

Clinical Decision ◽

Diabetic Woman

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A simulation-based approach to training in heuristic clinical decision-making

Diagnosis ◽

10.1515/dx-2018-0084 ◽

2019 ◽

Vol 6 (2) ◽

pp. 91-99 ◽

Cited By ~ 5

Author(s):

Ghazwan Altabbaa ◽

Amanda D. Raven ◽

Jason Laberge

Keyword(s):

Decision Making ◽

Clinical Decision Making ◽

Cognitive Biases ◽

Clinical Decision ◽

Order Effect ◽

Medical Residents ◽

Scenario Design ◽

Diagnostic Decision ◽

Momentum Bias ◽

Diagnostic Decision Making

Abstract Background Cognitive biases may negatively impact clinical decision-making. The dynamic nature of a simulation environment can facilitate heuristic decision-making which can serve as a teaching opportunity. Methods Momentum bias, confirmation bias, playing-the-odds bias, and order-effect bias were integrated into four simulation scenarios. Clinical simulation educators and human factors specialists designed a script of events during scenarios to trigger heuristic decision-making. Debriefing included the exploration of frames (mental models) resulting in the observed actions, as well as a discussion of specific bias-prone frames and bias-resistant frames. Simulation sessions and debriefings were coded to measure the occurrence of bias, recovery from biased decision-making, and effectiveness of debriefings. Results Twenty medical residents and 18 medical students participated in the study. Twenty pairs (of one medical student and one resident) and two individuals (medical residents alone) completed a simulation session. Evidence of bias was observed in 11 of 20 (55%) sessions. While most participant pairs were able to avoid or recover from the anticipated bias, there were three sessions with no recovery. Evaluation of debriefings showed exploration of frames in all the participant pairs. Establishing new bias-resistant frames occurred more often when the learners experienced the bias. Conclusions Instructional design using experiential learning can focus learner attention on the specific elements of diagnostic decision-making. Using scenario design and debriefing enabled trainees to experience and analyze their own cognitive biases.

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Intensive care decision-making: Identifying the challenges and generating solutions to improve inter-specialty referrals to critical care

Journal of the Intensive Care Society ◽

10.1177/1751143718758933 ◽

2018 ◽

Vol 19 (4) ◽

pp. 287-298 ◽

Cited By ~ 1

Author(s):

Nicola Power ◽

Nicholas R Plummer ◽

Jacqueline Baldwin ◽

Fiona R James ◽

Shondipon Laha

Keyword(s):

Intensive Care Unit ◽

Decision Making ◽

Intensive Care ◽

Clinical Decision Making ◽

Cognitive Biases ◽

Clinical Decision ◽

The Past ◽

Admission Decision ◽

Interviewing Technique ◽

Care Decision

Introduction Decision-making regarding admission to UK intensive care units is challenging. Demand for beds exceeds capacity, yet the need to provide emergency cover creates pressure to build redundancy into the system. Guidelines to aid clinical decision-making are outdated, resulting in an over-reliance on professional judgement. Although clinicians are highly skilled, there is variability in intensive care unit decision-making, especially at the inter-specialty level wherein cognitive biases contribute to disagreement. Method This research is the first to explore intensive care unit referral and admission decision-making using the Critical Decision Method interviewing technique. We interviewed intensive care unit ( n = 9) and non-intensive care unit ( n = 6) consultants about a challenging referral they had dealt with in the past where there was disagreement about the patient’s suitability for intensive care unit. Results We present: (i) a description of the referral pathway; (ii) challenges that appear to derail referrals (i.e. process issues, decision biases, inherent stressors, post-decision consequences) and (iii) potential solutions to improve this process. Discussion This research provides a foundation upon which interventions to improve inter-specialty decision-making can be based.

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A Laconic Lad

The Cognitive Autopsy ◽

10.1093/med/9780190088743.003.0022 ◽

2020 ◽

pp. 141-150

Author(s):

Pat Croskerry

Keyword(s):

Decision Making ◽

Clinical Decision Making ◽

Cognitive Biases ◽

Clinical Decision ◽

Contributory Factors ◽

Cognitive Failures ◽

Swiss Cheese Model ◽

The Common ◽

Hospital Emergency Departments ◽

Cheese Model

This case describes the clinical course of a young boy through an ophthalmology clinic and two hospital emergency departments. A variety of contributory factors led to his initial misdiagnosis and provide a good illustration of James Reason’s classic Swiss cheese model for the trajectory of an error through the system. Numerous cognitive biases and other cognitive failures occur along the way, including the classic déformation professionnelle. The case raises several important considerations about clinical decision making generally, especially the common confusion regarding correlation and causation.

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Enhancing Healthcare Decision-Making Process: Findings from Orthopaedic Field

Administrative Sciences ◽

10.3390/admsci10040094 ◽

2020 ◽

Vol 10 (4) ◽

pp. 94

Author(s):

Irene Schettini ◽

Gabriele Palozzi ◽

Antonio Chirico

Keyword(s):

Decision Making ◽

Clinical Decision Making ◽

Cognitive Biases ◽

Cognitive Distortions ◽

Clinical Decision ◽

Decision Making Process ◽

Healthcare Outcomes ◽

Post Discharge ◽

Whole Process ◽

Quality Control Tool

In the healthcare field, the decision-making process is part of the broad spectrum of “clinical reasoning”, which is recognised as the whole process by which a physician decides about patients’ treatments and cares. Several clinicians’ intrinsic variables lead to this decisional path. Little is known about the inference of these variables in triggering biases in decisions about the post-discharge period in the surgical field. Accordingly, this research aims to understand if and how cognitive biases can affect orthopaedists in decision-making regarding the follow-up after knee and hip arthroplasty. To achieve this goal, an interview-based explorative case study was run. Three key-decisional orthopaedic surgeons were interviewed through a quality control tool aimed at monitoring the causes and effects of cognitive distortions. Coherently with the literature, eight biases come to light. All the interviewees agree on the presence of four common biases in orthopaedic surgery (Affect heuristic, Anchoring, Halo effect, Saliency). The other biases (Groupthink, Availability, Overconfidence, Confirmation), instead, depending on specific physicians’ intrinsic variables; namely: (i) working experience; (ii) working context. This finding contributes to the debate about the application of cognitive tools as leverage for improving the quality of clinical decision-making process and, indirectly, enhancing better healthcare outcomes.

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