see also: [[Statistics and research methods overview#Forms of bias|Forms of bias in research]], [[Quality improvement]] > [!references]- > - [The cognitive biases of cognitive biases - EMA 2021](bookends://sonnysoftware.com/ref/DL/216097) > - [Cognitive errors in medicine: The common errors First 10 EM cubox](cubox://card?id=7217195697366371578) - [web](https://first10em.com/cognitive-errors/) > - [Cognitive errors in medicine: Mitigation of cognitive errors First10EM cubox](cubox://card?id=7217196102670355858) - [web](https://first10em.com/mitigation-of-errors/) > - [EMCrit 293 - The Jerk & Check, Functional Heuristics in Resuscitation](https://emcrit.org/emcrit/functional-heuristics-in-resuscitation/) > - [Cognitive biases and idioms table from Mya](x-devonthink-item://77B5EC76-1798-40CB-8B49-C6F58E8DA2BD) *“A safer system is one that accepts how humans think and designs to accommodate for that fact by changing work in order to maximise the chances for both success and the recognition and recovery from failure.”* **Downsides of considering cognitive bias as a means to reduce medical error:** - “An increased awareness of the cognitive biases of clinical decision making over the last decade has ==not resulted in a corresponding decrease in clinician error.== - "The inappropriate use of cognitive bias labels in adverse incident reviews can result in unintentional or intentional blame...” # Types of cognitive bias #tables note: it is not all-inclusive | bias | explanation | example | | -------------------------------- | --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ----------------------------------------------------------------------------------------------------------------------------------------------------- | | Affective error | - aka outcome bias<br>- tendency to convince yourself that what you want to be true is true | - think a friend's headache is benign<br>- think an annoying patient's chest pain is factitious | | Aggregate bias | - aka "ecological fallacy"<br>- belief that aggregate data, eg data from clinical trials, does not apply to an individual patient | CTB for child with low risk PECARN | | Ambiguity bias | - tendency to make a decision favouring the familiar and avoiding the ambiguous or uncertain, despite a lack of supporting evidence | - fever in returned traveller assume flu because you don't know about dengue | | Anchoring bias | prematurely settling on a single diagnosis based on a few important features of initial presentation and *failing to adjust when new information becomes available*<br>- may be compounded by confirmation bias | - hypotension and VBG shows elevated lactate and anchor on sepsis without considering cardiac failure | | Diagnostic momentum | similar to anchoring. once a diagnostic label assigned to a patient, difficult to remove that label and interpret the symptoms<br>- also similar to *premature closure* | Patient's symptoms are called "asthma" at triage, and continues to be treated as such, but actually upper respiratory obstruction | | Ascertainment bias | thinking is shaped by prior expectations; you see what you expect to see.<br>stereotyping and gender bias are types of ascertainment bias | homeless patient found unconscious assume it is OD but actually hypoglycaemia | | availability bias | eg "recent case bias"<br>opposite also true; if haven't seen a pathology in a while, might not think of it | See a case of septic ankle on instagram, diagnosis next ankle XR as septic<br>or Case from grand rounds and everyone starts making same diagnosis | | authority bias | tendency to attribute greater weighting to opinion of an authority figure<br>"eminence-based" medicine | | | Bandwagon effect | do certain things because others are doing so<br>"group-think" | heuristics in interns | | Base rate neglect | tendency to ignore true prevalence of a disease, either inflating or reducing its base-rate, distorting Baysian reasoning | eg over-estimate pre-test probability of PE | | Blind spot bias | belief that one is less susceptible to bias than others due to faith in their own introspections | | | Commission bias | tendency towards action rather than inaction; that "doing something" is better than doing nothing | low-risk patients with unnecessary tests or false positives leading to harm. | | omission bias | tendency towards inaction rather than action from fear of doing harm, even though greater harm by inaction | "under-resuscitating" because we don't want to "do any harm" | | Confirmation bias | one you have formed an opinion, a tendency to only notice evidence that supports that opinion and ignore contrary evidence | | | Framing effect | your decisions are affected by how you frame the question | you will miss right lower lobe pneumonia if you are only thinking about biliary colic | | Deformation professionnelle bias | viewing patient's problem from a single perspective only | neurologist thinks headache is a brain tumour, GP thinks its a migraine | | Dunning-kruger effect | confidence and competence do not evolve in parallel | | | fundamental attribution error | blame an individual for their problems rather than an external factor | clinician develops negative countertransferance towards patient and under-investigates | | Hawthorne effect | people behave differently when they know they are being watched | hand hygiene ↑ when being observed | | negativity bias | tendency to give more weight to negative experiences or information than neutral or positive ones | | | Triage cueing | when diagnostic decisions are influenced by the original triage category, notes, or area of department<br>- similar to diagnostic momentum | chest pain in fast track less likely to get an ECG | | premature closure | similar to *diagnostic momentum*<br>prematurely stop decision-making process and accept a conclusion before it has been verified | patient put in SSU on a "low risk chest pain clinical pathway" with negative troponin and missed pneumonia<br>- or renal-colic pathway and missed AAA | # Solutions to reduce cognitive biases - address fatigue - minimise interruptions - minimise time pressures - acknowledge one's emotions - SPIT DDx: identify the most - Serious diagnosis - Probable diagnosis - Interesting diagnosis - Treatable diagnosis - attempt to disconfirm