Cognitive bias: Its influence on clinical diagnosis

Strategies for reducing errors in the diagnostic process

Although the mental pathways involved in diagnostic reasoning have become better elucidated, there is still considerable controversy and uncertainty surrounding effective ways to counter errors. In their review of the literature, Norman et al concluded that diagnostic errors are multifactorial and that strategies that solely educate novice clinicians about biases are unlikely to lead to significant gains because of “limited transfer.”⁹ That is, in simply teaching the theory of cognitive errors before trainees have had time to accumulate real-world experience, they do not learn how to apply corrective solutions.

Graber et al argue that mental shortcuts are often a beneficial behavior, and it would be unrealistic and perhaps even detrimental to eliminate them completely from clinical judgment.¹³ Despite the controversy, several corrective methods have been proposed and have shown promise. Two such methods are medical education on cognitive error and the use of differential diagnosis generators.²

Medical education on cognitive error. If heuristics and biases are acquired subconscious patterns of thinking, then it would be logical to assume that the most effective way to prevent their intrusion into the clinical decision-making process would be to intervene when the art of diagnosis is taught. Graber et al reference several small studies that demonstrated a small improvement in diagnostic accuracy when learners were educated about cognitive biases and clinical judgment.¹³

Teaching the theory of cognitive errors before trainees have had real-world experience doesn't result in the application of corrective solutions.

Additionally, with medical students, Mamede et al describe how structured reflection during case-based learning enhanced diagnostic accuracy.¹⁴ However, none of these studies have proven that increased awareness of cognitive biases results in fewer delayed or missed diagnoses in clinical practice. Clearly, further research is needed to determine whether the skills gained in the classroom would be transferable to clinical practice and result in lower rates of delayed or missed diagnoses. Future studies could also investigate if these findings are replicable when applied to more experienced clinicians rather than medical students and residents.

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