COGNITIVE BIAS IN MEDICINE
MGR. BARBORA KÓŠA
DEPARTMENT OF PSYCHOLOGY AND PSYCHOSOMATICS
FACULTY OF MEDICINE
MASARYK UNIVERSITY
Begin early to make a threefold category—clear
cases, doubtful cases, mistakes. And learn to play the
game fair, no self-deception, no shrinking from the
truth; mercy and consideration for the other man,
but none for yourself, upon whom you have to keep
an incessant watch.
-Sir William Osler MD
Osler W. The student life. A farewell address to Canadian and American
medical students. The Medical News 1905(September 30);87(14):625–633.
Let’s begin with a case.
•Chief Complaint: “Get away from me”
•History of Present Ilness: 18 year old Hispanic male
presented by his Sergeant (SGT) for bizarre
behavior. According to the SGT, the patient has
been a mediocre soldier since the first day of boot
camp and a “slacker who can’t hack it.”
•He has been acting strangely for 2 days and making
a lot of sexual comments.
•According to one trainee, “he’s been looking for
attention to get kicked out” and has “refused to
train”. They feel 2 days ago he tried to hit his head
while getting out of a 5 ton truck to try to avoid
training.
Case
•Exam: Vital signs are normal
•Neuro: Non-focal
•Mental Status Examination: “Beautiful” mood,
sexual comments, later found by staff masturbating
in the evaluation room
•Skin: Small hematoma on right anterior scalp region
•Labs:
•Complete blood count, complete metabolic panel,
thyroid stimulating hormone, toxicology screen,
urine drug screen are within normal limits
Case Continued
Case: Questions to think about
•How do I as a physician diagnostically and clinically
approach this case?
•What are two significant thinking biases at risk in
this particular case?
•How would I prevent myself from making
cognitive/thought errors in order to reach an
accurate diagnosis?
MAIN AIMS
•Recognize and describe thinking (cognitive) biases
that may lead to diagnostic errors
•Recall typical cognitive steps involved in diagnostic
reasoning
Quick Question
•On the next slide, you will be asked to answer one
question.
•Answer it quickly and do not overthink it.
•Answer on your own without eliciting or giving help
to your peers.
•NOTE: If you are pulling out a calculator, you are
overthinking it!
Test Your Religious Knowledge
•How many animals did Moses place in the arc?
•A: 0
•B: 100,000
•C: unable to determine
•D: N (2) (where N= number of species)
Adapted from: Kahneman D. Thinking, Fast and Slow.
Macmillan; 2011.
American Psychiatric Association Annual
Meeting 2014 results, N=14
Why Should I Care?
•IMPROVED DIAGNOSTIC CLARITY
•Primary Care: Depression identified in only 47.3%
of cases
•DECREASED MORTALITY/MORBIDITY
•44,000 – 98,000 deaths per year
•5.07% of psychiatric patients experience a
medication error.
JAMA Intern Med. 2013 Dec 9-23;173(22):2063-8
Arch Intern Med. 2005;165(13):1493-1499
MISDIAGNOSIS:
Most Common Reason for Lawsuits
Misdiagnosis
72%
Others
28%
JAMA Intern Med. 2013 Dec 9-23;173(22):2063-8
75%
25%
Thought Error Others
Arch Intern Med. 2005;165(13):1493-1499
Other types of error
• Diagnostic
Error or delay in diagnosis; failure to employ indicated tests; use of outmoded
tests or therapy; failure to act on results of monitoring or testing
• Treatment
Error in the performance of an operation, procedure, or test; error in administering
the treatment; error in the dose or method of using a drug; avoidable
delay in treatment or in responding to an abnormal test; inappropriate (not
indicated) care
• Preventive
Failure to provide prophylactic treatment; inadequate monitoring or followup
of treatment
• Other
Failure of communication; equipment failure; other system failure
HOW WE AS CLINICIANS THINK…
Clinical Decision Making Process
Illness Scripts: Physician's image of diseases/
presentations that are used to match problem
representations.
Problem Representation (Summary): Physician's
restatement of the patient specific problem list.
Definitions:
Clinical Decision Making Process
1. Clinical Assessment: The patient presents with a set
of signs, symptoms, and clinical information that the
physician assesses.
2. Problem List: The physician creates a list of problems
for the patient presentation.
3. Problem Representation: The physician summarizes
the clinical presentation as a problem representation
(clinical summary)
Clinical Decision Making Process
4. Illness Scripts: The physician utilizes their repertoire
of illness scripts (all past clinical experience and
knowledge) and compares that mentally against the
current problem presentation.
5. Differential Diagnosis: The physician generates a
differential diagnosis for the problem presentation.
6. Diagnosis: The physician then selects a particular
diagnosis if able, or obtains further diagnostic testing
to rule something in or out.
N Engl J Med. 2006;355(21):2217-2225
Problem representation
• https://www.youtube.com/watch?v=8YhoREXzKLc
Let’s apply these 6 steps to our earlier
case…
•What is my problem representation in this
case?
•What are two significant cognitive biases at
risk in this particular case?
•How would I prevent myself from making
cognitive/thought errors in order to reach an
accurate diagnosis?
•CC: “get away from me”
•HPI: 18 yo Hispanic male presented by his Sergeant
(SGT) for bizarre behavior. According to the SGT, the
patient has been a mediocre soldier since the first
day of boot camp and a “slacker who can’t hack it.”
•He has been acting strangely for 2 days.
•According to one trainee, “he’s been looking for
attention to get kicked out” and has “refused to
train”. They feel 2 days ago he tried to hit his head
while getting out of 5 ton truck to try to get out of
training where he now has a bruise.
•He has also been making a lot of sexual comments.
Case
•Exam: Vital signs are normal
•Neuro: non-focal
•MSE: “beautiful” mood, sexual comments, later
found by staff masturbating in the evaluation room
•Skin: small hematoma on right anterior scalp region
•Labs:
•Complete blood count, complete metabolic panel,
urinalysis, thyroid stimulating hormone, toxicology
screen, urine drug screen are within normal limits
Case Continued
Clinical Decision Making Process
1. Clinical Assessment:
History, Physical,
Additional Diagnostic
Tests
2. Problem List: The
physician creates a list of
problems for the patient
presentation.
3. Problem Representation:
The physician
summarizes the clinical
presentation as a
problem representation
(clinical summary)
1. History, Physical,
Additional Diagnostic
Tests
2. (Subjective) Bizarre
behavior, subpar
performance, head injury,
strange; (Objective)
hypersexual, disinhibited,
scalp hematoma
3. 18 year old Hispanic male
Soldier with 2 days of
disinhibition, hyper
sexuality following mild
head trauma.
Clinical Decision Making Process
1. History, Physical,
Additional Diagnostic
Tests
2. (Subjective) bizarre
behavior, subpar
performance, head injury,
strange; (Objective)
hypersexual, disinhibited,
scalp hematoma
3. 18 year old Hispanic male
Soldier with 2 days of
disinhibition,
hypersexuality following
mild head trauma.
4. Illness Scripts: What
would explain
disinhibition and
hypersexuality following
mild head trauma?
5. Differential Diagnosis:
Trauma, Seizure,
Malingering
6. Diagnosis: Needs head
imaging to rule out
trauma/bleed
Dual Process Theory
• Recognition
• Gestalt
• Heuristic Biases
• Normative
reasoning
• Bayesian
• Exhaustive
strategy
Intuitive/FAST Analytical/SLOW
DECISION
Science. 1974;185(4157):1124-1131.
Factors influencing which system is employed
• Task complexity
• S1 – typical signs and symptoms
• S2 – atypical symptoms, complex cases
• Expertise
• S2 – novices, students
• accuracy of systems 2 thinking depends on knowledge base, expertise..
The diagnostic
evidence base and
clinical practice
• 13 000 conditions in
International
Classification of
Diseases, 9th Edition
(2015)
• primary care physicians
627.5 h/month of
reading to keep up to
date (Alper et al., 2004)
-> acknowledge clinical
teams, follow systematic
reviews and clinical
practice guidlines
Heuristics:
•Cognitive shortcuts that permit clinicians to use a
“FAST” thinking approach via the use of pattern
recognition.
• For example, seeing a patient with grandiose delusions and pressured
speech leading to a rapid differential with the most-likely diagnosis
being bipolar disorder.
•Advantage
• Reduce time and effort to make reasonably good judgments and
decisions.
•Disadvantage:
• Potential to lead to systematic cognitive errors called biases.
More Definitions:
Acad Med. 2011 Mar;86(3):307-13.
Cognitive Biases
•Use of Heuristics, with its intent on speed,
can lead to biased reasoning and
misdiagnosis
•Numerous patterns of erroneous thinking
have been identified and are now labeled
•Next several slides show common cognitive
biases
Acad Med. 2011 Mar;86(3):307-13.
• IMAGINE a basketball player
• IMAGINE a math competition winner
• IMAGINE a person diagnosed with anorexia
• IMAGINE a heart attack
Representativeness bias
• Only saying these words can create an image of prototypical patient
based on a clinician’s experience and the textbook descriptions of
these cases.
• Clinicians spend large amounts of time on data collection to make
precise diagnoses possible. In most cases, lung cancer patient is going
to be an older smoker.
• Beware of exceptions to stereotypical descriptions. Some lung cancer
patiens are going to be young who never smoked before.
Representativeness bias
• “how likely is it that this patient has a particular disease?” by
assessing how typical the patient’s symptoms are for that disease
• tendency to make decisions based on a typical case, „textbook
disease example“
• highly typical symptoms (e.g., fever and nausea after contact with an
individual from West Africa with Ebola virus), then it is likely the
patient will be diagnosed as having that condition (e.g., Ebola virus
infection).
Representativeness bias
• errors can also occur when there is an over-reliance on a patient’s
demographic factors or behaviors, as opposed to their clinical
presentation.
• atypical presentations are not protected from the disease!
Representativeness bias study
• The potential of stereotypes to mislead clinicians was demonstrated
in a study by Triplet. Subjects were provided with a patient with
vague symptoms, such as fatigue and recurrent infections.
• Participants were given descriptions of five diseases: influenza,
leukemia, AIDS, meningitis, and appendicitis, which were chosen in
part because their symptoms often overlap.
• determine the most likely diagnosis.
• When told that a female patient was a homosexual, subjects rated
her as being more likely to have AIDS than a heterosexual woman
with identical symptoms.
• Although lesbians are in fact less likely to contract AIDS than
heterosexual women, because they were broadly categorized in the
higher risk group of “homosexuals,” they were inappropriately judged
to be at higher risk than heterosexual women
Imagine you examine a patient with symptoms of mild depression. In
the last 3 months he was observing changes in his sleeping patterns,
his negative thoughts are more frequent and persistent, he decsribes
himself as being anxious, irritable and has lost his apetite.
No major life changes or stressors preceeded this health condition.
After careful consideration, you are assured, that no contraindication
regarding medication are present.
Half of students (those of you closer to the
window)
CLOSE YOUR EYES
Is the probability estimate for markedly remission from
depressive symptoms lower or higher than 25%?
Please write down your probability estimate of remission from
depressive symptoms as a result of treatment with this medication.
OPEN YOUR EYES
Second half of students (those of you closer to the
door)
CLOSE YOUR EYES
Is the probability estimate for markedly remission from
depressive symptoms lower or higher than 75%?
Please write down your probability estimate of remission from
depressive symptoms as a result of treatment with this medication.
OPEN YOUR EYES
WHAT NUMBERS DID YOU WRITE?
Anchoring bias
• Initial number created an anchor, starting point for your reasoning
• all future negotiations, arguments, estimates, etc. are discussed in relation to the anchor
• When we decide, sometimes we rely on first information we encounter
• Our reasoning can be affected by very unlikely values or data
In an experiment by Strack and Mussweiler (1999), respondets were asked whether Mahatma
Gandhi died before or after age 9, or before or after age 140 (groups guessed average age of 50
vs. average age of 67)
• Example: You see a T-shirt for 1200 USD, then you see one for 100 USD –> you’re
prone to see the second shirt as cheap. Whereas, if you’d merely seen the
second shirt, priced at $100, you’d probably not view it as cheap
• Often used in negotiations
Anchoring Bias in medicine
•Focus on features in the patient's initial
presentation too early in the diagnostic process
without adjusting the outcome when further
information are available.
A patient is admitted from the emergency department with a diagnosis of
heart failure. The hospitalists who are taking care of the patient do not pay
adequate attention to new findings that suggest another diagnosis.
~ Premature closure, Confirmation bias
Acad Med. 2011 Mar;86(3):307-13.
Acad. Med. 2003;78:775–780.
Framing bias
• Would you rather choose MEDICATION A with „cure rate 95%“ or
MEDICATION B with „failure rate“ 2,5 %?
• Loss aversion - losses and gains are perceived differently and people
make choices based more on perceived gains than perceived losses.
If a person has to choose between two equal options, they are more
likely to choose the one that is framed as a gain over one that is
framed as a loss
• Beware of how information about treatment is presented !
Framing bias example
To see how framing might affect a clinician’s judgment, imagine you are in the
middle of an epidemic and have to choose one of two treatment options
In the following scenario, choose A or B:
A. 80% chance to save 1,000 people, 20% chance to save 0.
B. Save 700 for sure.
This choice is a high chance of significant gains. Most people will favor a risk
adverse strategy and choose B, even though the expected value of A is higher.
In the following scenario, choose A or B:
A. 80% chance to kill 1,000 people, 20% chance to kill 0.
B. Kill 700 for sure.
This is framed in terms high risk of significant loss. Most people will favor a
risk seeking strategy and choose A, even though the expected value of B is
higher.
Emotional Bias
•Negative or positive feelings towards patient
influences diagnosis (counter-transference)
• Obese patients, non-adherent patients, chronic pain,
“borderline”
• Famous patients, important patients, attractive patients
• outcome bias – physician favors tests/treatments which
won’t mean significant consequences for patient
• Tendency to opt for treatments with previous positive outcomes, rather than the
evidence supporting the treatment at the time of diagnosis
Acad Med. 2011 Mar;86(3):307-13.
Acad. Med. 2003;78:775–780.
Availability Bias
•Recall of diagnostic or other information because it
happens to be a recent experiences
•Can be induced by media exposure, previous case…
•For example: A day after confirming diagnosis of
temporal lobe seizures causing auditory
hallucinations, your next patient is thoroughly
reviewed by your for temporal lobe seizures because
it’s a “fresh” and “available” entity in your mind.
Acad Med. 2011 Mar;86(3):307-13.
Acad. Med. 2003;78:775–780.
Unpacking Bias
•Failure to elicit all pertinent information to make
diagnosis.
Example: failing to obtain collateral of
Spice abuse resulting in misdiagnosis of
primary psychosis.
Acad Med. 2011 Mar;86(3):307-13.
Acad. Med. 2003;78:775–780.
Diagnosis Momentum
•Once diagnostic labels are attached to patients, they
tend to become stickier and stickier. What might have
started as a possibility gathers increasing momentum
until it becomes definite, and all other possibilities are
excluded.
Example: DEEEFFFINTELY A BORDERLINE!!
Acad Med. 2011 Mar;86(3):307-13.
Acad. Med. 2003;78:775–780.
Confirmation Bias
•Notice and consider only those signs and symptoms
that favor our hypothesis and ignore aspects
inconsistent with it.
Acad Med. 2011 Mar;86(3):307-13.
Acad. Med. 2003;78:775–780.
Base rate neglect
• This occurs in medicine when the underlying incident rates of
conditions, or population based knowledge are ignored as if they do
not apply to the patient in question.
Psychologists are looking for trauma and dissociation, because these are
„exotic“, but often don‘t realize its prevalence in population
Overconfidence bias
•Universal tendency to believe that we know more
than we do.
• This bias encourages individuals to diagnose a disease based on incomplete
information; too much faith is placed in one’s opinion rather than on
carefully gathering evidence. This bias is especially likely to develop if
clinicians do not have feedback on their diagnostic performance.
Blind Obedience
•Showing undue deference to authority or
technology
•“Neurological etiologies ruled-out by the
neurology consultant.”
•“The ED has medically cleared the patient.”
Back to the Case…
•What is my problem representation in this case?
•What are two significant cognitive biases at risk in
this particular case?
•How would I prevent myself from making
cognitive/thought errors in order to reach an
accurate diagnosis?
Example of Cognitive Biases from the
Case
• Emotional (also known as visceral) bias:
• Everyone is pointing at the Soldier to be a “slacker” and a “failure”. You feel
like “this guy is trying to manipulate me to get out of the Army.” It makes you
dislike the patient and “know for sure” he’s just a malingerer.
• Alternatively, you “hate to see kids getting bullied.” You promise yourself that
“I have to advocate for this guy and protect him from the Army.” You end up
missing malingering and expose the soldier to unwanted additional testing.
• NOTE: emotional biases can be negative or positive. It’s a problem when that
undesirable dislike or over-identification with the patient leads to erroneous reasoning.
• Blind obedience:
• The Emergency Room physician calls you and tells you that “I’ve got a good
one for you.” You are told the patient is medically cleared and needs to be
hospitalized. You take this information at face value. Subsequent head
imaging shows patient had a head bleed.
• The high ranking Sergeant for the Soldier tells you “exactly what’s going on
with the Soldier. He’s just been a pain since Day 1 and is just malingering.”
You again decide to go with the Sergeant’s word and miss a head bleed.
So What Do We Do About It?
Cognitive Forcing Strategies
• Activate known cardinal rules or caveats
• Look back at problem representation
• Deciding when to switch from “Fast” thinking to “Slow” thinking
analytical mode
• Decreasing the processing ease of an argument reduced confirmation
bias effects (graphical inconsistency of information – mind maps,
fonts..)
Disfluency
• Confirmation bias is reduced when information is presented in a
disfluent format
- Less confirmation bias when evaluating capital punishment arguments
- Jurors give less confirmatory verdicts after reading a disfluent summary of a
crime (written in italics...)
- Confirmation biases were observed more often under cognitive load (time
pressure)
(Hernandez, Preston, 2013)
Metacognition
• Monitoring decision making - deliberative examination of one’s own
reasoning
• Expert practice requires reflection for growth
• Routine expert (apropriately uses preexisting knowledge to quickly
solve routine, familiar or uncomplicated problems) / adaptive expert
(able to employ a deep conceptual understanding and engage in
reflection to create novel solutions for complicated or unfamiliar
problems...)
• Healthy scepticism about own thought processes
(Royce et al., 2019)
Techniques for metacognition
• Create alternative hypothesis „What else could this be?“
• Consider-the-opposite – create argument list, why your primary diagnosis
might not be correct -> lowers hindsight bias, overconfidence, anchoring
(Mussweiler, 2000)
• Estimate your own accuracy with given diagnosis – lowers overconfidence
bias
• Diagnostic time-out (explicit pause to reflect on the thinking process leading
to the diagnosis) especially at patient handoff / when confronted with
complex case
• Keep a journal/patient log for further learning or self-reflection
Checklists and related tools
• SPECIFIC: Diagnostic accuracy can be improved by using checklists
with typical „not-to-miss“ symptoms or diagnoses / GENERAL: “Again
try to reevaluate your decision.“
• Specific checklists with symptoms were shown to be more effective
• Catheter infections were significantly reduced in Michigane Keystone
ICU project (2006) with implementation of 5 steps checklist (wash
your hands, old catheter disposal...)
• Only 8% of physicians were willing to use checklists...(Saposnik et al.,
2016)
• Perspective change : prospective hindsight, think like an outsider
Get help from other people/use decision
tools
• Reach out for help - ask for feedback and enhance communication
with multidiciplinary team
• Get second opinions
• get intensive, detailed, specific feedback
• Learn from errors
• Use specialist consultants & second opinions; improve team-based decisions,
for example, by having a devil’s advocate
• routine meetings, supervision, mentoring
Reduce reliance on memory
• Use of guidelines, clinical algorithms, linear models and mnemonics
• Improve medical records
• Improve data display through graphics
• Use decision support tools
Acknowledge your limits...
• Decision fatigue - worsened ability to decide and overcome easy solutions as a
result of multiple previous decisions
• decision fatique and antibiotic prescription
• N= 204 physicians
• Odds ratio of antibiotic prescription raised with hours spent in
service (the chance of prescribing antibiotics was highest before
lunch – “easy choice“)
• REMEDIES
• Support tools for decision making according time of the day
• Regular breaks and snacks(Linder et al., 2014)
• Create solid knowledge base
• Search for objective data
• Understand statistical prediction rules
• Rule-out the worst-case scenario
Practical Steps
1. Take a step back: Think about thinking.
•Am I confident in the diagnosis?
• If yes, question yourself
• Thorough Self Appraisal of Perspective, Previous Mistakes, Diagnostic
Ambiguity, and Evaluation of Potential Cognitive Bias
• If no, go to step 2
Practical Steps (continued)
2. Gather additional data.
• Additional history and exam
• Collateral information
• Additional testing and consultation
• Consider delaying diagnosis (symptom based approach)
3. Re-evaluate and return to Step 1.
Diagnostic Card
Pair-Group Discussion
• One of you start with presenting the case on your sheet to your
partner
• Partner receiving presentation will be asked questions at the end by
the presenting partner
• 10 minutes
• After the first case, we will take a break for large group discussion
• 5 minutes
• Partners switch and repeat the above for the second case
Case 1 Distribution
• 10 minutes pair discussion
• 5 minutes large group discussion
Case 2 Distribution
• 10 minutes pair discussion
• 5 minutes large group discussion
Conclusions
• Thought errors are a leading cause of morbidity, mortality in
medicine and entail medico-legal implications.
• Understanding how we think and make decisions highlight our
tendencies to commit cognitive errors.
• Insight into our unique tendencies and biases may help reduce our
diagnostic errors.
• Meta-cognition (thinking about our thinking) is the first step in
helping us assess our confidence level when dealing with diagnostic
data.
• Use of the provided checklist on the card and familiarity with
common cognitive biases in your daily practice may help in your
clinical maturation process.
How would you feel after making diagnostic
mistake?
https://www.youtube.com/watch?v=GxGe8HMbJOg
EMOTIONAL CONSEQUENCES OF MISTAKES
• 80s‘ – personal stories of feeling inadequate, incompetent, guilty after medical
error...
• doctor seen as a second victim
• PTSD-like symptoms after error (Wolf)
• Image of perfection in healthcare -> not prepared to confront error
Second victims are healthcare providers who are involved in an unanticipated adverse patient
event, in a medical error and/or a patient related injury and become victimized in the sense
that the provider is traumatized by the event. Frequently, these individuals feel personally
responsible for the patient outcome. Many feel as though they have failed the patient, second
guessing their clinical skills and knowledge base
• “No matter how much you fool yourself you are over something, and maybe even
though I hadn’t thought of it for months, I had that woman’s name seared into my
memory and as soon as I saw that name, my chest was up in my throat.I still think
about it. Just randomly you forget and then something will happen and it just pops
into your head. You go over it again, what could I have done differently, what could I
have said, what should I have done?“
• “I remember feeling horribly sad that I couldn’t do more for this child. This hit me
harder than most of them. For some reason I really related with this family—I guess
one reason is that the child was the age of my oldest daughter and I guess that I felt
that this could have been my family. They were a nice family and didn’t deserve to
have this outcome. I cried a lot over this case and I guess I still cry when I think about
her. “
How would you feel after taking part in
medical error?
PHYSICAL SYMPTOMS
• Extreme fatigue
• Sleep disturbances
• Rapid heart rate
• Increased blood pressure
• Muscle tension
• Rapid breathing
• PSYCHOSOCIAL SYMPTOMS
• Frustration
• Decreased job satisfaction
• Anger
• Extreme sadness
• Difficulty concentrating
• Flashbacks
• Loss of confidence
• Grief
• Remorse
• Depression
• Repetitive/intrusive memories
• Self-doubt
• Return to work anxiety
• Second guessing career
• Fear of reputation damage
• Excessive excitability
• Avoidance of patient care area
• 31 interviews, ½ year to 36 years experience
• 17 psychosocial + 6 physical symptoms more than 10x
• predictable trajectory – stages
STAGES OF RECOVERY
• CHAOS Right after the event and during the code, I was having trouble concentrating. It was nice to have people take
over, that knew what they were doing, that I trusted. I was in so much shock. I don’t think I was as useful as I usually am
during a code situation.
• INTRUSIVE REFLECTIONS „I started to doubt myself. This shouldn’t have happened. It was all hindsight but I kind of kept
thinking over and over again. There were some things that I thought maybe if I’d have done it this way, it wouldn’t have
happened or been avoided. Everything was clearer looking at things in retrospect. I lost my confidence for some time.“
• SUPPORT SEEKING ‘‘Do they think of me everyday as this loser who doesn’t know what is going on?’’, I thought, ‘‘These
people are never going to trust me again’’.
• Depends on organisational culture, overlooking mistake or gossip frustrates
• ENDURING THE INQUISITION – „What are the consequences going to be? How is it going to influnece my career?“
• EMOTIONAL FIRST AID Nobody wanted to talk about it. I am not a touchy, feely person but I at least needed someone to
make sure I was doing okay and I never felt like that. I felt like, ‘‘Well, this happens and you should be better about it and
that’s it.’
• MOVING ON - dropping out, surviving or thriving
• medical error creates cognitive disonance
COGNITIVE DISSONANCE
• Not a bias itself but leads to many biases
• mental discomfort (psychological stress/uncomfortable feeling) that
we get when
• Two beliefs (values/ideas) that we hold are inconsistent with each other
• Our beliefs are inconsistent with our behaviour
• Triggered by a situation in which a person's belief clashes with new
evidence perceived by the person
• Example
• Treatment is not effective
This leads to
• Self-justification – mental gymnastics that allow us to maintain the
view that we are competent and correct
• Confirmatory bias – we search for information that tells us we are
right
• Blaming others...
REDUCTION OF COGNITIVE DISSONANCE
• motivation to lessen mental stress by actions that reduce the
magnitude of the dissonance
• Change the behavior or the cognition ("I'll eat no more of this doughnut.")
• Justify the behavior or the cognition, by changing the conflicting cognition
("I'm allowed to cheat my diet every once in a while.")
• Justify the behavior or the cognition by adding new behaviors or cognitions
("I'll spend thirty extra minutes at the gym to work off the doughnut.")
• Ignore or deny information that conflicts with existing beliefs ("This
doughnut is not a high-sugar food.")
Remedies for your own dissonance
• Recognise that reducing dissonance is a strong drive
• Be aware of the distortions that arise from dissonance
• Be vigilant for the feeling of discomfort due to dissonance and be vigilant
about being open to new information
• Be open to the possibility of error
• Dissonance is human, be willing to experience it
• Prevent bad decision after bad decision in self-justification !
Klein (2019)
• especially for young doctors – perfectionism,
„good doctor does not make mistakes“...
WHAT ARE POSSIBLE CONSEQUENCES OF THAT STATEMENT?
‘A good doctor learns from mistakes. It’s not
that a good doctor never makes mistakes.’
I have not been successful in dealing with a paradox: I am a healer, yet I
sometimes do more harm than good. Obviously, we physicians must do
everything we can to keep mistakes to a minimum. But if we are unable to deal
openly with those that do occur, we will find neurotic ways to protect ourselves
from the pain we feel. Little wonder that physicians are accused of playing
God. Little wonder that we are defensive about our judgments, that we blame
the patient or the previous physician when things go wrong, that we yell at
nurses for their mistakes, that we have such high rates of alcoholism, drug
addiction, and suicide. At some point we must all bring medical mistakes out of
the closet. This will be difficult as long as both the profession and society
continue to project their desires for perfection onto the doctor. Physicians need
permission to admit errors. They need permission to share them with their
patients. The practice of medicine is difficult enough without having to bear
the yoke of perfection.
(Howard, 2019)
RECOMMENDED READING
• Croskerry, P. (2003). The importance of cognitive errors in diagnosis
and strategies to minimize them. Academic medicine, 78(8), 775-780.
• Croskerry, P. (2002). Achieving quality in clinical decision making:
cognitive strategies and detection of bias. Academic Emergency
Medicine, 9(11), 1184-1204.
• Howard, J. (2019). Cognitive Errors and Diagnostic Mistakes. Springer
International Publishing.
• MORE ON CRITICAL THINKING
Neil Thompson & Jan Pascal (2012) Developing critically reflective
practice, Reflective Practice, 13:2, 311-325, DOI:
10.1080/14623943.2012.657795