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Cognitive biases in internal medicine: a scoping review

  • Michael F. Loncharich ORCID logo EMAIL logo , Rachel C. Robbins , Steven J. Durning , Michael Soh und Jerusalem Merkebu
Veröffentlicht/Copyright: 21. April 2023
Diagnosis
Aus der Zeitschrift Diagnosis Band 10 Heft 3

Abstract

Background

Medical errors account for up to 440,000 deaths annually, and cognitive errors outpace knowledge deficits as causes of error. Cognitive biases are predispositions to respond in predictable ways, and they don’t always result in error. We conducted a scoping review exploring which biases are most prevalent in Internal Medicine (IM), if and how they influence patient outcomes, and what, if any, debiasing strategies are effective.

Content

We searched PubMed, OVID, ERIC, SCOPUS, PsychINFO, and CINAHL. Search terms included variations of “bias”, “clinical reasoning”, and IM subspecialties. Inclusion criteria were: discussing bias, clinical reasoning, and physician participants.

Summary

Fifteen of 334 identified papers were included. Two papers looked beyond general IM: one each in Infectious Diseases and Critical Care. Nine papers distinguished bias from error, whereas four referenced error in their definition of bias. The most commonly studied outcomes were diagnosis, treatment, and physician impact in 47 % (7), 33 % (5), and 27 % (4) of studies, respectively. Three studies directly assessed patient outcomes. The most commonly cited biases were availability bias (60 %, 9), confirmation bias (40 %, 6), anchoring (40 %, 6), and premature closure (33 %, 5). Proposed contributing features were years of practice, stressors, and practice setting. One study found that years of practice negatively correlated with susceptibility to bias. Ten studies discussed debiasing; all reported weak or equivocal efficacy.

Outlook

We found 41 biases in IM and 22 features that may predispose physicians to bias. We found little evidence directly linking biases to error, which could account for the weak evidence of bias countermeasure efficacy. Future study clearly delineating bias from error and directly assessing clinical outcomes would be insightful.

Keywords: bias; clinical reasoning; cognitive biases; debiasing; medical error
Corresponding author: Michael F. Loncharich, MD, Rheumatology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA; Uniformed Services University, Bethesda, MD, USA, Phone: (301) 295-4512, E-mail:

Acknowledgments

We would like to thank Candace Norton for her assistance in designing and executing our literature search.

  1. Research funding: None declared.

  2. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  3. Competing interests: Authors state no conflict of interest.

  4. Informed consent: Not applicable.

  5. Ethical approval: Not applicable.

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Supplementary Material

This article contains supplementary material (https://doi.org/10.1515/dx-2022-0120).

Received: 2022-11-07
Accepted: 2023-03-30
Published Online: 2023-04-21

© 2023 Walter de Gruyter GmbH, Berlin/Boston

Artikel in diesem Heft

  1. Frontmatter
  2. Review
  3. Cognitive biases in internal medicine: a scoping review
  4. Opinion Papers
  5. “Pivot and Cluster Strategy” in the light of Kahneman’s “Decision Hygiene” template
  6. Developing a European longitudinal and interprofessional curriculum for clinical reasoning
  7. Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic error (SPADE): comparison groups to maximize SPADE validity
  8. Reframing context specificity in team diagnosis using the theory of distributed cognition
  9. Original Articles
  10. Promoting clinical reasoning with meta-memory techniques to teach broad differential diagnosis generation in a pediatric core clerkship
  11. Semantic competence and prototypical verbalizations are associated with higher OSCE and global medical degree scores: a multi-theory pilot study on year 6 medical student verbalizations
  12. Influence of comorbid depression and diagnostic workup on diagnosis of physical illness: a randomized experiment
  13. Recognition, diagnostic practices, and cancer outcomes among patients with unintentional weight loss (UWL) in primary care
  14. Quantitation of neurofilament light chain protein in serum and cerebrospinal fluid from patients with multiple sclerosis using the MSD R-PLEX NfL assay
  15. Analysis of common biomarkers in capillary blood in routine clinical laboratory. Preanalytical and analytical comparison with venous blood
  16. Comparison between cerebrospinal fluid biomarkers for differential diagnosis of acute meningitis
  17. Short Communications
  18. Exploring relationships between physician stress, burnout, and diagnostic elements in clinician notes
  19. Development of a student-created internal medicine frameworks website for healthcare trainees
  20. Case Report - Lessons in Clinical Reasoning
  21. Lessons in clinical reasoning – pitfalls, myths, and pearls: a case of crushing, substernal chest pain
  22. Letters to the Editor
  23. Ample room for cognitive bias in diagnosing accidental hypothermia
  24. Auscultation order of lung and heart sounds and autonomous noise cancellation
  25. Reliability of a single-nostril nasopharyngeal swab for diagnosing SARS-CoV-2 infection
https://doi.org/10.1515/dx-2022-0120
Schlagwörter für diesen Artikel
bias; clinical reasoning; cognitive biases; debiasing; medical error

Artikel in diesem Heft

  1. Frontmatter
  2. Review
  3. Cognitive biases in internal medicine: a scoping review
  4. Opinion Papers
  5. “Pivot and Cluster Strategy” in the light of Kahneman’s “Decision Hygiene” template
  6. Developing a European longitudinal and interprofessional curriculum for clinical reasoning
  7. Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic error (SPADE): comparison groups to maximize SPADE validity
  8. Reframing context specificity in team diagnosis using the theory of distributed cognition
  9. Original Articles
  10. Promoting clinical reasoning with meta-memory techniques to teach broad differential diagnosis generation in a pediatric core clerkship
  11. Semantic competence and prototypical verbalizations are associated with higher OSCE and global medical degree scores: a multi-theory pilot study on year 6 medical student verbalizations
  12. Influence of comorbid depression and diagnostic workup on diagnosis of physical illness: a randomized experiment
  13. Recognition, diagnostic practices, and cancer outcomes among patients with unintentional weight loss (UWL) in primary care
  14. Quantitation of neurofilament light chain protein in serum and cerebrospinal fluid from patients with multiple sclerosis using the MSD R-PLEX NfL assay
  15. Analysis of common biomarkers in capillary blood in routine clinical laboratory. Preanalytical and analytical comparison with venous blood
  16. Comparison between cerebrospinal fluid biomarkers for differential diagnosis of acute meningitis
  17. Short Communications
  18. Exploring relationships between physician stress, burnout, and diagnostic elements in clinician notes
  19. Development of a student-created internal medicine frameworks website for healthcare trainees
  20. Case Report - Lessons in Clinical Reasoning
  21. Lessons in clinical reasoning – pitfalls, myths, and pearls: a case of crushing, substernal chest pain
  22. Letters to the Editor
  23. Ample room for cognitive bias in diagnosing accidental hypothermia
  24. Auscultation order of lung and heart sounds and autonomous noise cancellation
  25. Reliability of a single-nostril nasopharyngeal swab for diagnosing SARS-CoV-2 infection
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