August 11, 2013

162017_132140396847214_292624_nIn an article appearing on June 27, 2013 in the New England Journal of Medicine, the effect of cognitive bias in reaching incorrect diagnoses was discussed. It was noted that the rate of diagnostic errors is estimated to be between 10% and 15%, with the rate highest for specialties such as emergency medicine, family medicine, and internal  medicine where patients are diagnostically undifferentiated (a group diagnosis in which there is no differentiation from the anatomic pathology diagnosis) while the rate of diagnostic errors in the visual specialties (radiology and pathology) is around 2%.

The human mind (“thought”) is known to be vulnerable to cognitive biases, logical fallacies, false assumptions, and other reasoning failures, which include medical clinicians (there are more than 100 biases affecting clinical decision making that have been identified). Addressing cognitive bias as a cause of diagnostic errors is important (for example, the diagnosis of pulmonary embolism was missed 55% of the time in a series of fatal cases, many of which were due to cognitive bias).

The human brain manages and processes information (“reasoning”) in two different ways: automatically (“intuitively”) and in a controlled manner (“analytically”). In intuitive processing, the reasoning is largely reflexive and autonomous and is either hard-wired or acquired through repeated experience; it is subconscious and fast. Intuitive reasoning is important and useful to conducting much of the activities of our daily lives. Because intuitive reasoning is without conscious reflection involving fixed-action patterns, the fixed-action patterns are most susceptible to cognitive biases, fallacies, and thinking failures.

Improving the potential negative consequences of employing intuitive reasoning in the clinical setting is difficult because many clinicians are unaware of their biases due to psychological defense mechanisms that prevent them from examining their thinking, motivation, and desires too closely, and/or many clinicians are unaware of or do not appreciate the effect or influence of intuitive reasoning on their clinical decision-making.

The New England Journal of Medicine article provides the following example of possible negative consequences of intuitive reasoning in the clinical setting: when a primary care physician trusts his intuition that his patient’s chest pain is not a cardiac event, he will usually be correct, but not always.

In contrast, analytical reasoning is conscious, deliberate, slower, and generally reliable; it follows the laws of science and logic and more likely to be rational. However, analytical reasoning is more resource-intensive and would be impractical to employ in each clinical decision. Using the same example of a patient experiencing chest pain, when the patient undergoes an analytic assessment for his chest pain in a cardiac clinic that results in angiography, the conclusion is always correct. However, analytic decision-making is susceptible to failures due to following the wrong rules if there is cognitive overload, fatigue, sleep deprivation, or emotional disturbances.

Cognitive biases in clinical decision-making can be influenced by using “debiasing” strategies: the clinician must be vigilant and mindful of his own thinking so that when a cognitive bias is identified, a deliberate decoupling from the intuitive mode and an intentional engagement of the analytic mode may be made. However, debiasing is extraordinarily difficult to accomplish. The New England Journal of Medicine article notes, “debiasing is not easy, no one strategy will work for all biases, some customization of strategies will be necessary, and debiasing will probably require multiple interventions and lifelong maintenance … [c]ognitive failures … can be addressed by educational strategies that embrace critical thinking — the ‘ability to engage in purposeful, self-regulatory judgement’ … critical thinking can be taught and cultivated, but even accomplished critical thinkers remain vulnerable to occasional undisciplined and irrational thought.”


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