Diagnostic Reasoning &

Cognitive Bias
PDS5.31 NUMed 2016
Dr Tim Smith
Study Guide Says…
 Is Diagnosis Important?

• Arguably the most important thing that

doctors do.
• Determines the treatment prescribed.
• Whilst some patients may recover in spite of
incorrect treatment, more will recover with
the correct treatment.
 How do we make a diagnosis?
The clinical reasoning process can be summarized as consisting
of five steps:
1. identification (and collection) of the clinical information that
is relevant to the diagnosis; -History (and examination)
2. interpretation of its meaning;
3. generation of hypotheses which provide a coherent
explanation of the patients problem;
4. testing and refining of those hypotheses through further
data collection; -Investigations
5. establishment of a working diagnosis.

Elstein 1978
The importance of the History

Peterson, Holbrook et al. West J Med 1992

“Listen to your patient. He is
telling you the diagnosis”

William Osler 1849-1919

 Certainty Requires More Data

Led to Correct Confidence in

Diagnosis (%) Diagnosis (/10)

History 78.58 6.36

Examination 8.17 7.57

Investigations 13.27 9.84

Roshan & Rao 2000

 So it’s simple...
(Detailed) History
+
(Competent) Clinical Examination
+
(Appropriate) Investigations
=
Confident & Accurate Diagnosis
 But we still get it wrong...

Overall diagnostic error rate approx. 10-15%.

And patients suffer...

Harvard Medical Practice Study. NEJM 1991

 ...and die.

Top alleged medical error named in claims where the patient expired.
Physician Insurers of America Data Sharing Project 1985-2009.
Physician Insurer 2010.
 Why do we get it wrong?
No Fault:
•Atypical presentation
•Deception by patient

System-Related:
•Technical 13/228
•Organisational 215/228

•Cognitive:
•Faulty knowledge (11/320)
•Faulty data gathering (45/320)
•Faulty synthesis (264/320)

Usually multifactorial av. 5.9 errors per misdiagnosis.

Faulty synthesis the most common error.
Graber et al. Arch Intern Med. 2005;165:1493-1499
 No Fault Errors
• Deception (intentional or unintentional)
• rarely intentional
• special care with patients unable to give clear history

• Atypical presentation
• new conditions or presentations
• should reduce in number as medical knowledge an
technology improves
 System-Related Errors
• Technical Errors e.g. malfunctioning machine
• relatively infrequent
• Organisational errors
• common but potentially correctable if recognised
• importance of QC and QA programmes
• but new solutions may create new problems
e.g. reducing working hours lessens errors due to
fatigue but increases errors due to miscommunication
at patient handover
• must seek to minimise total error at organisational level
 Cognitive Errors
• Faulty knowledge (3%)
• Uncommon (if you stick to your area of expertise)
• Research indicates improvement with experience
• Faulty data collection (15%)
• Many potential sources of error: language barrier, cultural gap, poor
communication skills (Dr or pt), competence in examination, access
to investigations.
• Fatigue, overwork (system problems) may promote.
• Also improves with experience
• Faulty synthesis/interpretation/data processing (82%)
• The most common type of cognitive error
• Doubt about whether it improves with experience
How Do We Process Information?

Croskerry 2009

Lots of psychological models. If only there were a unifying theory…

 Dual Process Theory
Non-Analytical/Intuitive

Analytical/Rules Based Croskerry 2009

Type I & Type II processes occur in parallel and interact with each other.
fMRI demonstrates anatomical separation of the two pathways.
 Contrasting Characteristics
Type 1 Type 2
• Intuitive/Heuristic • Logical Rule Based
• Automatic/Reflexive • Need conscious effort
• Fast • Time Consuming
• Low mental effort • High mental effort
• Context Specific • Context independent
• Vulnerable to bias • Immune to bias

e.g. spot diagnosis e.g. Bayes theory (Pprior, LR+/-)

pattern recognition
 Conventional Medical Wisdom
• Type 1 = BAD
• Prone to bias
• Not under logical control

• Type 2 = GOOD
• Rational
• Infallible (or at least less error prone)

Except that…
If we always relied on type 2 processes
we’d never get anything done...

vs.

Type 1 -
Type 2 - intuitive
analytical
Type 2 processes aren’t always better

Mamede et al. Psychological Research 2010

“Experience is fallacious
and judgement difficult.”

Hippocrates 460-370 BC
 Potential Sources of Error in Type 2
Processes and Possible Solutions
• Wrong rules:
• Applying the wrong rule
• Applying a rule wrongly
• Wrong information:
• Distraction (Cognitive Overload)
• Failure to recognise signs/symptoms
• Failure to ask the question
• Focus and take time
• Improve knowledge
• Reflect (
 Errors (Biases) Affecting Type 1
Processes and Potential Solutions
>100 influences on intuitive choices described...
• Anchoring: tend to stick to first impressions.
• Framing: accepting a prior statement of the problem.
• Premature Closure: making a diagnosis without considering all the
possibilities.
• Confirmation bias: only taking note of results that support your
hypotheses.
• Search Satisficing: stopping looking after the first positive finding.
• Deference to authority: accepting the facts as told to you by someone in a
position of authority.
• Diagnostic momentum: labels tend to stick.
• Availability: tendency to judge diagnoses as more likely if they are easier
to retrieve from memory (recently seen, recent lecture, interesting).
 How can we avoid diagnostic error?

• We can’t.
“Human beings in all lines of work make errors.”
To Err is Human: Building a Safer Health System 1999

• Several methods proposed to reduce error:

• Cognitive debiasing
• Computer assisted diagnosis
• Checklists
• None convincingly shown to work.
So...my (not very evidence based) advice
• Consider and the worst case scenario:
• What’s the worst thing this might be?
• Am I sure it’s not that?
• See lots of patients:
• good pattern recognition requires a large database of patterns.
• Metacognition:
• Be aware of your potential biases:
– (unfortunately there’s little evidence that we can overcome them)
• Understand the rules you’re applying and the tests you rely on.
• Accept uncertainty and error check yourself:
• Can my diagnosis explain all the findings?
• Assuming I’m wrong what else could it be?
• Discuss cases with your colleagues.
• Follow up your patients and learn from your mistakes.
The father of modern medicine says...

“One finger in the throat

and one in the rectum
makes a good
diagnostician.”

William Osler 1849-1919