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210 Errors and cognitive bias
by anchoring and availability biases. For example, a consultant makes a
denitive diagnosis of normal pressure glaucoma on optic disc appearance,
and then, the patient continues to lose vision. Eventually, they are found to
have a space-occupying lesion compressing the optic nerve.
●
Representativeness bias: Restraining decision making along pattern restraint
recognition, which may miss atypical diseases. Misinterpreting the likelihood
of an event considering both the key similarities to its parent population,
and the individual characteristics that define that event. is can be seen in a
man who has classic symptoms of a heart attack, is anxious and whose breath
smells of alcohol. e latter details have no bearing on the likelihood of a
heart attack nor do they alter the degree to which he is a member of his risk
demographic, but they can distract and decrease the diagnostic pickup.
●
Search-satisfying bias: Ceasing to look for further information or alternative
diagnoses when the first plausible solution is found. Within the time-pressured
environments doctors work in, this is an ever-increasing source of bias. A clini-
cal example is assessing a short-of-breath patient in casualty and diagnosing
pneumonia but missing their heart failure, which exacerbates their dyspnoea.
●
Diagnostic momentum bias: Once diagnostic labels are attached to a patient,
they can gather momentum and make it harder to change course. ey become
xed in the clinical record, and subsequent clinicians can simply propagate the
diagnosis rather than question it when faced with disparate features. e typical
example is a diagnosis made by a consultant and then supported and propa-
gated unquestioningly by the junior doctors despite atypical features devel-
oping, such as xating on a previously assigned label of ‘possible pulmonary
embolism’ and organising CT imaging for a patient who may have subsequent
results that suggest otherwise (e.g. positive blood cultures the following day).
●
Framing bias: Pervasive in clinical practice and oen seen in the eld of
radiology. It occurs when a clinician reacts in a specic way dependent upon
how the information is presented. For instance, an MRI is requested query-
ing a cerebellar abnormality. e cerebellum is reported as being normal,
but a pituitary tumour is missed. e radiologist focuses on the area they are
asked about and fails to assess the scan as a whole.
●
Omission bias: A tendency towards inaction grounded in the principle of do
no harm. It is avoidance of active intervention to alter disease progress and
the incorrect acceptance of any deterioration as natural history rather than
clinician inaction. A tendency towards action rather than inaction. Oen, this
is the easiest course but can result in patient dissatisfaction if it is the wrong
course of action. ‘You should have done something to spare me 3 years of pain’.
●
Premature closure bias: Akin to diagnostic momentum bias. e diagnosis
is made, and the game is won. No further thought is given to the condition
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Solutions 211
and the case is closed. All further eort is directed to treatment rather than
formulation of the diagnosis.
●
Hindsight bias: e inability to realistically appraise past events once the
outcome becomes known. We continue to develop and grow as clinicians.
We should always strive to learn from our errors and those of others. e
appraisal process should allow us to develop and prevent future hindsight
bias; however, this can result in availability bias and over-investigations.
●
Triage-cueing bias: Either through patient self-diagnosis or within the pre-
referral triage systems of the NHS, the patient is sent in a particular direction
and may start the process of diagnostic momentum. Referral to a transient
ischaemic attack (TIA) clinic may facilitate discounting of a TIA as the cause
of the patient’s symptoms but will not determine the underlying cause.
●
Visceral bias: We all warm to some patients more than others. Aggressive or
confrontational patients will get our backs up, but those are the ones who
are most likely to complain if an error occurs. is bias relates to the rst
impression on meeting the patient. It may generate positive or negative feel-
ings, which may aect decision making.
●
Zebra retreat bias: Refers to the natural reticence to consider a rare diagno-
sis, even though it is the most likely. ‘It cannot be x, as the patient is only 20
years old’. e need to exclude the most serious condition is paramount, and
retreating from a diagnosis because it is unlikely will inevitably lead to harm
and misdiagnosis for some clinicians (and patients) somewhere at some time.
e laws of probability apply to us all.
SOLUTIONS
Cognitive bias is prevalent and a source of signicant errors. As health care pro-
fessionals, we must recognise our fallibility and put in place personal or systemic
processes to mitigate the risks.
ere is no quick x. We work in a pressured environment, and though many of
these biases are found to be causative of errors, they are also vital processes in our
clinical practice. We cannot set aside our training and our gut feeling for fear of bias.
Pattern recognition is a vital tool for us. We are supposed to try and make denitive
diagnoses in order to move the process forward and develop management strategies.
In addition, we have demanding patients who want action to remedy their
problems.
We do not have enough time to bring them back for endless tests that may
refute or conrm their preliminary diagnosis. We also need to trust our col-
leagues, and rather than revisit every diagnosis from scratch, we should be
guided by the previous diagnosis. Expecting a clinician to ditch all of these bed-
rock features of our clinical practice is unreasonable.
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212 Errors and cognitive bias
e rst step in correcting a problem is recognising it. e only way to do this
is to set ego aside and realise that we are fallible. Experienced clinicians have been
practising medicine successfully by utilising all of the techniques we label as biases
for many years. ey rarely fail them, and in the vast majority of situations, they
are correct. However, they are also likely to be the most set in their ways. ey will
lock in on a diagnosis and fail to question themselves and reconsider the diagnosis.
We are all aware of the need for reection, and we routinely reect on learn-
ing opportunities and clinical errors aer the fact. It is vital that we reect on our
practice on an ongoing basis and realise that we are prone to errors. Recognising
that and having insight is vital to prevent future errors.
As the main tool for preventing cognitive bias and errors, metacognition is
a reective approach to problem solving that involves stepping back from the
immediate problem to examine and reect on the thinking process behind a
diagnosis or a management plan. It is the awareness of and insight into one’s
own thought processes. Such insight forces clinicians to ask themselves ‘what else
could this be, and am I condent that this is the correct diagnosis?’
Focused teaching in these issues is needed to educate clinicians to recognise
where they may be prone to bias. Encouraging a team approach is also vital. If
there is diagnostic uncertainty or a fear that a cognitive error has occurred, then
asking a colleague’s opinion is a low-stress way of getting an objective opinion.
eir understanding of the potential for bias will allow an objective assessment of
the decision-making process. From a medicolegal perspective, getting a second
opinion shows clinical insight and emphasises the reasonableness of our actions.
e best strategy to avoid diagnostic errors is also the most unrealistic and
unachievable in modern medical practice. Slowing down is the ideal solution.
is allows the diagnostician to transition into type 2 thinking, reflect more
critically on the data and ultimately make fewer errors.
6,
7
When faced with
deliberate availability bias, medical students who were forced to slowly deliberate
performed better, and diagnostic accuracy was shown to improve by simply slow-
ing cognition in two other studies.
8,
9
With increasing demands, how can the clinician be expected to slow down?
Unfortunately, courts do not take into account how busy the clinic was or how
far behind schedule we were. Any case is considered in the cold light of day, and
‘I only have ten minutes for each patient’ or ‘my clinic was massively overbooked’
is unfortunately given short shri.
Checklists and protocols are important debiasing strategies that may facilitate
and sometimes challenge the diagnostic thought process. Soware can assist cli-
nicians in agging common diagnoses and pointing to protocols. Checklists are
used to good eect in any industry to prevent errors.
Ultimately, cognitive bias is a major contributor to medical errors and is
underrepresented in education and neglected in clinical practice. Clinicians
need to be aware of it and constantly challenge and double-check themselves.
Clinicians do not have to do this in isolation, however, and it is vital that systems
and teams are in place to recognise and mitigate these biases.
It is unrealistic to expect doctors to abandon the strategies they use regularly
and that are oen valued as good skills simply because they may be the source
of bias. However, doctors should recognise that these tried-and-tested skills they
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Solutions 213
pride themselves on may result in bias and diagnostic errors. We should all lower
our threshold for considering the likelihood of cognitive bias in the hope of rec-
ognising it sooner and remedying it before harm occurs.
Slowing down is impossible, but setting aside details of a patient we are unsure
of in order to consider them at the end of our clinic when we have time to engage
our type 2 thinking is a sensible precaution. Asking for advice or a second opin-
ion is another tool that should be used more frequently.
Klein et al.
4
summarised rules for decision making, namely:
●
Slow down.
●
Be aware of base rates for your dierentials.
●
Consider what data are truly relevant.
●
Actively seek alternative diagnoses. Do not be afraid of questioning yourself
or others.
●
Ask questions to disprove your hypothesis.
●
Remember, you are oen wrong. Consider the immediate implications of
this and remedy this early.
Achieving these goals may be impossible, but the attempt should still be made to
avoid problems for ourselves and potentially prevent harm to our patients.
REFERENCES
1. Kassirer, J. P., & Kopelman, R. I. (1989). Cognitive errors in diagnosis:
Instantiation, classification, and consequences. American Journal of
Medicine, 86, 433–41.
2. Graber, M. L., Franklin, N., & Gordon, R. (2005). Diagnostic error in inter-
nal medicine. Archives of Internal Medicine, 165, 1493–1499.
3. Hershberger, P. J., Part, H. M., Markert, R. J., Cohen, S. M., & Finge,
W.W. (1994). Development of a test of cognitive bias in medical decision
making. Academic Medicine, 69, 839–842.
4. Klein, J. G. (2005). Five pitfalls in decisions about diagnosis and prescrib-
ing. BMJ, 330, 781–783.
5. Kahneman, D. (2003). Maps of bounded rationality: psychology for
behavioural economics. American Economic Review, 93, 1449–1475.
6. Kahneman, D. (2011). Thinking, Fast and Slow (1st ed.). Farrar, Straus and
Giroux.
7. Croskerry, P. (2003). The importance of cognitive errors in diagnosis and
strategies to minimize them. Academic Medicine, 78, 775–8024.
8. Mamede, S., van Gog, T., van den Berge, K., Rikers, R. M. J. P., van Saase,
J. L. C. M., van Guldener, C., & Schmidt, H. G. (2010). Effect of availabil-
ity bias and reflective reasoning on diagnostic accuracy among internal
medicine residents. JAMA, 304, 1198–1203.
9. Schmidt, H. G., Mamede, S., van den Berge, K., van Gog, T., van Saase,
J.L. C. M., & Rikers, R. M. J. P. (2014). Exposure to media information
about a disease can cause doctors to misdiagnose similar-looking clinical
cases. Academic Medicine, 89, 285–291.
https://t.me/med1917
214
37
Improving diagnosis
The causes of diagnostic errors are multifactorial, but some of the most common
are cognitive and knowledge-based, such as decision-making biases, heuristics
and misjudgements; lack of knowledge; technical errors; and communication
failure. No matter the cause, the result is the same: a delayed or missed diagnosis
that costs the patient their time, suering and sometimes their lives.
For doctors, the resulting complaints and/or potential litigation are also
extremely stressful. ere is the risk of facing allegations of professional miscon-
duct and clinical negligence as well as guilt if a wrong diagnosis leads to harm or
loss of life. Either way, this is a scenario we want to avoid.
Unfortunately, diagnostic errors are among the costliest and most poten-
tially devastating medical errors, and they occur frequently. In settings ranging
from primary care to high-level tertiary care, these are prevalent. In the past
decade, diagnostic errors have been identied as a serious problem in the medi-
cal literature.
According to the NHS Resolution, in 2018/19, there were 10,678 new clini-
cal negligence claims in the NHS.
1
While the numbers were comparatively low
considering the high number of patients served by the NHS, the fact remains
that many missed and late diagnoses go undetected. According to Elliott et al.,
there are 237 million errors each year in medication alone, 71% of which occur
in primary care.
2
No accurate data exist that can robustly identify the rate of
true errors; however, according to some studies, 70% of all medical errors are
diagnostic errors.
3
e consequences of a missed or wrong diagnosis vary based on the speciality,
level of hospital (primary/secondary/tertiary), system conditions, etc.
According to a study focusing on emergency medicine, between 2013 and 2015,
there were 5,412 cases reported for diagnostic errors.
4
e numbers themselves
may not be among the highest within specialities; however, given the nature of
the diseases and conditions people visit EDs with, the consequences are graver
than dermatological diagnostic errors, for example.
Most missed diagnoses in EDs are myocardial infarction, intracranial bleeds
and fractures, of which hip and spine fractures are the most common types.
Suce to say, missing these diagnoses can lead to patient death and permanent
DOI: 10.1201/9781003179351-46
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A case in point 215
damage. Naturally, the clinical negligence claims and potential payouts can
be signicant. e hospital in which a patient is attended to is a factor as well.
Although diagnostic errors have been discussed primarily in hospital settings,
research suggests that they also occur frequently in primary care environments.
e most common types of diagnostic errors are misdiagnosis (e.g. appendi-
citis), missed diagnosis (e.g. melanoma) and delayed diagnosis (e.g. lung cancer).
An individual’s cognitive abilities play a role in diagnostic errors, in addition to
system factors aecting patient safety, which can sometimes contribute to these
errors more than individual factors do.
A very common cause is aws in clinical reasoning. It is dicult to identify a
correct diagnosis when a patient’s symptoms and signs do not conform to expec-
tations. Our ability to catalogue all possible disease presentations has not kept
pace with our expanding knowledge of diseases. Additionally, unanticipated
presentations may be due to diseases we have yet to discover or understand or to
nuances within conditions we see frequently.
According to Wellbery, aws in reasoning are oen caused by the internal cog-
nitive biases of professionals.
5
Cognitive biases are mostly heuristics or shortcuts
physicians use to reach a diagnosis. Most are tried-and-true methods developed
through a physician’s experience. e risk of this method is that some diagnoses
will fall through the patterns, which may have been easy to spot without the
bias. In fact, according to some authors, ‘75% of errors in internal medicine are
thought to be cognitive in origin’.
6
Cognitive errors are discussed in depth in Chapter 36. Cognitive biases, by
their nature, are hard to detect.
A CASE IN POINT
7
A female patient in her 50s reported to the hospital with a rapidly progressing
weakness while visiting Mexico. She rst developed mild muscle pain, which
progressed to leg weakness and then the inability to stand. Aer hospitalisation,
the weakness moved upwards towards her upper extremities and neck. She was
le unable to move her hands and legs but had a stable respiratory status. ere
was bilateral severe proximal worse than distal weakness in all limbs. She was
found to have long-term facial paraesthesia and dry mouth.
While an inpatient in Mexico, a visiting professor was asked to diagnose the
patient. Aer taking her history, he diagnosed her condition as acute trichino-
sis. e rationale behind his diagnosis was that the patient was visiting Mexico
and she could have contracted trichinosis, which was consistent with the typi-
cal proximal worse than distal weakness of the limbs, sparing the respiratory
muscle and face and preserving the reexes. At rst glance, the diagnosis seemed
accurate.
However, a framing bias was in eect. e diagnosis was based on the rst
information that was provided, which was that the patient was in Mexico when
her conditions rst developed. e professor was also provided her blood test
results, which showed she had abnormal serum potassium, high ESR, rheumatoid
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216 Improving diagnosis
factors and Sjögren syndrome A and B antibodies. e lab results pointed to the
correct diagnosis, which was hypokalaemia due to distal renal tubular acidosis
caused by Sjögren’s.
Another case study showed a common scenario at the NHS: anchoring and
premature closure. As physicians are pressed for time, they will oen diagnose
based on the chief complaints given by the patient. For example, when a patient,
obese with normal to high blood sugar, presented with a rash below their arms,
it was reasonably diagnosed as intertrigo. e diagnosis was highly likely, so the
GP would probably have asked them to return if the rash did not disappear.
However, the patient had pain in their joints, which was not mentioned in
their rst visit. e patient later went to another doctor, who diagnosed them
with arthritis and referred them to a rheumatologist. It was at the rheumatologist
where the correct diagnosis was discovered: erythema migrans associated with
Lyme disease.
8
e rst two doctors focused on only one symptom, and the sys-
temic condition eluded them.
Nevertheless, cognitive biases, or heuristics to be exact, are an eective tool
to improve diagnosis, even though they may lead to errors. ere are hundreds
of possible clinical diagnoses for each symptom. To reach the most probable one,
a clinician needs to be able to read the patterns of a patient’s symptoms through
training/repetition, which is aided by heuristics.
Heuristics save time and resources and are undeniably necessary to be a good
health care professional.
Making decisions based on intuition or previous knowledge is how we make
diagnoses and clinical judgements on a day-to-day basis, unless there are any
indications to not do so, such as sensitive cases or worsening patient condi-
tions. According to Rottman, most physicians use Bayesian reasoning to reach
a diagnosis.
9
Bayesian reasoning is simple: ‘the most important determinants of the pos-
terior probability of disease are the prior probability and the test properties’.
10
is means that the known probability of a disease and the test results/symptoms
shown by a patient determine the probability of that patient having the disease.
For example, if a patient has pox-like spots, they may be either chickenpox or
smallpox. But the doctor already knows the chances of chickenpox are higher
than smallpox; hence, coupled with the symptoms, the most probable disease the
patient has is chickenpox. Although the use of Bayesian reasoning is not deliber-
ate, it is intuitive and an inherent part of heuristics.
e conclusions doctors reach based on their own knowledge and experience
are usually more likely to be correct than those based on data, such as prevalence
rates. erefore, knowledge-based decisions cannot be cast away, but they will be
wrong sometimes.
As mentioned in an earlier chapter, cognitive psychologists propose two
types of thinking that portray the duality in the diagnostic process. One type
of thinking process is intuitive, fast and based on patterns or ‘rapid autonomous
processes’, called type 1 thinking. e other type is based on ‘distinctive higher
order reasoning processes’ or on the analysis of available data and logical reason-
ing. is type is called type 2 thinking.
10,
11
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A case in point 217
Type 1 thinking refers to fast, automatic, intuitive and eortless thinking.
ese types of decisions are based on mental shortcuts or heuristics. e diag-
nosis is made using the physician’s experience and pattern recognition (i.e. they
have seen this before). Type 2 thinking refers to slower, more analytical and more
eortful thinking. e diagnosis is based on methodical exploration and patient
examination. It oen involves ordering further tests, reviewing current medica-
tions and consulting with colleagues or a specialist. To reach a correct diagnosis,
we need both.
Metacognition is a practical approach to using both systems. e theory of
metacognition can be dened as ‘the capacity for self-reection on the process of
thinking and self-regulation in monitoring decision making’.
12
In other words, it
is the use of type 2 thinking to reassess or reect on the decisions reached with
type 1 thinking.
is type of self-reection can be used by clinicians to help them make more
accurate decisions about diagnoses and treatments. e concept of metacogni-
tion is not new. Many proponents and researchers advocate it as a critical skill for
medical professionals to develop. e idea behind this approach to clinical rea-
soning is that clinicians must develop the ability to reect on their own thinking
processes. e practitioner must be able to thoroughly examine the steps taken
prior to, during and aer an event to accurately diagnose a patient’s problem.
According to Heneghan et al., the diagnostic process can be divided into three
steps: initiation of diagnostic hypotheses, renement of the diagnostic hypotheses
and dening the nal diagnosis.
13
Dividing it gives more control over each step
and a specic set of tools to employ at each step.
e rst stage is the initiation of the diagnosis. It occurs within the rst few
minutes of consultation. Some strategies that can be used in this stage are:
●
Spot diagnosis: at is the unconscious recognition of non-verbal patterns
or symptoms; for example, a teenage patient coming to the dermatologist
with several large areas of acne or a patient visiting their GP with a barking
cough. Physicians of the associated speciality can identify the patterns shown
by the symptoms immediately. Sixty-three per cent of these conditions do
not need further diagnostic tests, as doctors would recognise them as easily
as they would their relatives, according to Sackett et al.’s ‘Auntie Minnie’
phenomenon.
14
●
Self-labelling: A patient may tell the physician what they think they have.
Self-labelling may be accurate in some cases but can result in framing bias
errors. If a patient has chronic conditions, for example, or recurring infec-
tions, taking their opinion into account increases the probability of a correct
diagnosis. ey also use ‘Dr Google’ to aid in their self-diagnoses.
●
Chief complaint: e initial diagnosis or dierential diagnosis should
always address the chief complaint of the patient. However, the associated
complaints may also point to the correct diagnosis, and it is the clinician’s
professional obligation to tease out those associated symptoms through
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218 Improving diagnosis
questioning. For example, to a patient, ‘feeling thirsty more oen’ or ‘having
to use the bathroom more’ is not as signicant as the recurring infections/
ulcers they have, but these lead to a potential diagnosis of diabetes.
e second stage is the renement stage. In this stage, the clinician renes the
choices or ideas they made. e strategies for this step are:
●
Restricted rule-outs: Murtagh’s restricted rule-out is an excellent tool to
rule out disorders/diseases until we are le with the most probable one. In
the diagnostic process, a restricted rule-out is a strategy that lists the possible
diagnoses, which are eliminated in stepwise fashion aerwards. e elimi-
nations are based on test results, further symptoms, disease progression/
evolution, etc. For example, the patient’s clinical features might t an initial
diagnosis, but the laboratory result is inconsistent with it, resulting in the
removal of the diagnosis.
●
Stepwise renement: A stepwise renement is a process in which the initial
complaint is narrowed down to an anatomical site or pathological process.
Next, the possibilities are eliminated stepwise until the correct diagnosis is
reached. For example, a red and itchy eye may be local or systemic. Once the
root cause is conrmed as local, such as conjunctivitis, the next step is to
determine whether the conjunctivitis is infectious or allergic.
●
Pattern recognition: Recognising the patterns of symptoms and the pat-
terns of previous patients is not only helpful for diagnosis but also prepares a
physician for the possible outcomes of diseases and treatments.
●
Clinical prediction rules: ese are handy for new doctors and are oen
available as part of the EPR soware. ey are essentially patterns associ-
ated with diseases formalised with repetitive use. Clinical rules and patterns
established by experienced clinicians are usually well tested and reliable.
Streptococcal sore throat rules, depression HAD scores, DVT (Wells rule)
and the ABCDE of emergency patient management are excellent examples of
existing rules that apply well and can help reach reasonable goals.
15,
16
e nal stage of diagnosis is to ne-tune the narrowed-down list and choose one
diagnosis that is the most likely. Oen, this is done in the clinician’s head; how-
ever, should the diagnosis be wrong, it is important that the thought process is
documented clearly. If there is no evidence that other diagnoses were scrutinised
and excluded, then we leave ourselves open to allegations of ‘failed to consider’.
As stated earlier, a clinician owes a duty of care to the patient to consider all
potential diagnoses, but sometimes, they will pick the incorrect one. By itself,
making a wrong diagnosis is not a breach of duty as long as it was reasonable to
do so, and the same decision would have been reached by a reasonable body of
medical opinion.
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Computer assistance 219
e strategies that help physicians achieve this last renement step with mini-
mal mistakes are:
●
Test s : If the diagnosis is still unclear aer the previous strategies have been
exhausted, then the best course of action is to order more tests. While these
tests are being arranged, it is reasonable to commence treatment for the
most harmful condition on the dierential diagnosis list. More information
narrows down or directs the possibilities, and the potential correct diagnosis
should be clearer.
●
Known diagnosis: Treatment can be started aer a sucient idea regard-
ing the disease has been formed, depending on the nature of the disease and
the level of certainty required from the physician. If the treating physician
is a GP, their job is to suspect an acute condition, start the initial treatment
and refer to the closest available secondary care provider. e nature of the
disease determines whether an accurate diagnosis is needed or not.
For example, conjunctivitis caused by dierent pathogens has the same
management, so determining the pathogen type is not needed, unless the
symptoms dier from the norm and there is a concern that there is a sight-
compromising pathology.
17
●
Test of treatment and time: is is a common and ecient strategy used
by most physicians to minimise the need to bring patients back on multiple
occasions. If we cannot conrm a diagnosis with 100% surety, a strategic
move is to commence treatment and place a safety net by asking the patient
to return if the symptoms do not subside within a given amount of time.
e treatment may conrm the diagnosis or refute it. It is part of the diagnostic
process. For example, giving an inhaler for night cough can be used to conrm
or refute a diagnosis of bronchospasm. Diseases that are usually transient can be
waited out, given there are no serious symptoms.
For example, a nursery child having acute sensitivity in their palms and feet
with soreness of the throat can be assumed to have hand-foot-mouth disease. Most
GPs would not advise any treatment apart from sore throat management and wait-
ing for a few days to see whether the condition improves or worsens. As long as
there is adequate safety netting that is clearly relayed to the patient, ideally in writ-
ten form, then even if the diagnosis is wrong, the potential harm is mitigated.
COMPUTER ASSISTANCE
Making a diagnosis is still very much a clinician’s job, but computers can make
the process easier, safer and more ecient. e use of EPRs in the NHS, for exam-
ple, allows a doctor to assess all available data of a patient in one place, giving
them enough information to reach a dierential diagnosis.
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