High-risk Situations for Biased Reasoning in Teaching Residents Table
(Adapted by L..Sommers from Table 1 in “Cognitive Debiasing, Part 1:Origins of bias and theory of debiasing” Croskerry, Singhal, & Mamede, published in BMJ Quality
& Safety, 9/13)
Situation
1. Was this patient’s behavior issues already suggested to
me by another provider, nurse, or other worker?
2. Did I just accept my first conclusion about this
patient’s issues?
3. Did I consider the full range of sources of this patient’s
behavior issues (e.g., cognitive,
emotional/psychological, structural, interpersonal)
before I settled on the problem being.........
4. Is this a patient I don’t like, or like too much?
5. Had I been interrupted or distracted while working
with this patient?
6. Was I tired or in bad spirits during the patient
encounter?
7. Was I cognitively overloaded or over-extended during
the patient encounter
8. Am I stereotyping this patient?
9.
Have I effectively ruled out not-to-be-missed learning
issues and opportunities from this patient?
Potential Bias
Diagnostic momentum, premature closure, framing
Anchoring, availability, search satificing, premature closure
Anchoring, search satisficing, premature closure
Affective bias
Affective bias + others
Affective bias + others
Affective bias + others
Representative bias, affective bias, anchoring, fundamental
attribution
(new concept – ‘implicit bias’ Chapman et al, JGIM 2013)
Overconfidence, anchoring,
confirmation bias
Definitions of Common Cognitive Biases
(Experienced in the course of diagnostic/therapeutic decision making for patients; Croskerry, “The Importance of Cognitive Errors in Diagnosis
and Strategies to Minimize them,” Academic Medicine 2003)
Affective bias: tendency for emotional factors originating from general human dispositions ( e.g., the desire for good outcomes and the avoidance
of misery) or from responses to individual patient characteristics (e.g., stereotyping) to affect clinical decision making
Anchoring: tendency to perceptually focus on salient features in patient’s initial presentation at too early a stage in diagnostic process, and to not
adjust the initial impression to information that comes available later.
Availability: the tendency to judge things as being more likely, or occurring frequently occurring if they easily come to mind (e.g., recent experience
with a disease may inflate the likelihood of its being diagnosed, or if disease not diagnosed recently, will be underdiagnosed.
Confirmation bias: tendency to look for confirming evidence to support diagnosis as opposed to looking for disconfirming evidence to refute it,
despite the latter sometimes being more salient and believable.
Diagnosis momentum: once diagnostic labels are attached to patients they tend to stick with increasing force. Spread by others (patients,
paramedics, nurses, physicians), what could have started as a possibility develops momentum until it becomes definitive and other diagnoses
become excluded.
Framing effect: how diagnosticians see things may be strongly influenced by how the problem is framed, e.g., physicians’ perceptions of
risk to the patient may be influenced by whether the outcome is expressed in terms of the possibility that the patient might die or might live.
Fundamental attribution error: tendency to be judgmental and blame patients for their illnesses (dispositional causes) rather than examine the
situational factors that might have been responsible. (Psychiatric patients, minorities, and other marginalized groups are common targets of this bias.)
Overconfidence bias: the tendency to believe we know more than we do and reflecting the tendency to act on incomplete information, intuitions, or
hunches. Too much faith is placed in opinion instead of carefully gathered evidence; may be augmented by both anchoring and availability.
Premature closure: accepting a diagnosis before it has been fully verified.
Representativeness restraint: the tendency to look for prototypical manifestations of disease: ‘‘If it looks like a duck, walks like a duck, quacks like
a duck, then it is a duck.’’
Search satisfying: calling off the diagnostic process once a plausible diagnosis is found.