A cognitive forcing tool to mitigate cognitive bias:A randomised control trial

Abstract Background Cognitive bias is an important source of diagnostic error yet is a challenging area to understand and teach. Our aim was to determine whether a cognitive forcing tool can reduce the rates of error in clinical decision making. A secondary objective was to understand the process by which this effect might occur. Methods We hypothesised that using a cognitive forcing tool would reduce diagnostic error rates. To test this hypothesis, a novel online case-based approach was used to conduct a single blinded randomized clinical trial conducted from January 2017 to September 2018. In addition, a qualitative series of “think aloud” interviews were conducted with 20 doctors from a UK teaching hospital in 2018. The primary outcome was the diagnostic error rate when solving bias inducing clinical vignettes. A volunteer sample of medical professionals from across the UK, Republic of Ireland and North America. They ranged in seniority from medical student to Attending Physician. Results Seventy six participants were included in the study. The data showed doctors of all grades routinely made errors related to cognitive bias. There was no difference in error rates between groups (mean 2.8 cases correct in intervention vs 3.1 in control group, 95% CI -0.94 – 0.45 P = 0.49). The qualitative protocol revealed that the cognitive forcing strategy was well received and a produced a subjectively positive impact on doctors’ accuracy and thoughtfulness in clinical cases. Conclusions The quantitative data failed to show an improvement in accuracy despite a positive qualitative experience. There is insufficient evidence to recommend this tool in clinical practice, however the qualitative data suggests such an approach has some merit and face validity to users

What You Find Depends on How You Measure It: Reactivity of Response Scales Measuring Predecisional Information Distortion in Medical Diagnosis

“Predecisional information distortion” occurs when decision makers evaluate new information in a way that is biased towards their leading option. The phenomenon is well established, as is the method typically used to measure it, termed “stepwise evolution of preference” (SEP). An inadequacy of this method has recently come to the fore: it measures distortion as the total advantage afforded a leading option over its competitor, and therefore it cannot differentiate between distortion to strengthen a leading option (“proleader” distortion) and distortion to weaken a trailing option (“antitrailer” distortion). To address this, recent research introduced new response scales to SEP. We explore whether and how these new response scales might influence the very proleader and antitrailer processes that they were designed to capture (“reactivity”). We used the SEP method with concurrent verbal reporting: fifty family physicians verbalized their thoughts as they evaluated patient symptoms and signs (“cues”) in relation to two competing diagnostic hypotheses. Twenty-five physicians evaluated each cue using the response scale traditional to SEP (a single response scale, returning a single measure of distortion); the other twenty-five did so using the response scales introduced in recent studies (two separate response scales, returning two separate measures of distortion: proleader and antitrailer). We measured proleader and antitrailer processes in verbalizations, and compared verbalizations in the single-scale and separate-scales groups. Response scales did not appear to affect proleader processes: the two groups of physicians were equally likely to bolster their leading diagnosis verbally. Response scales did, however, appear to affect antitrailer processes: the two groups denigrated their trailing diagnosis verbally to differing degrees. Our findings suggest that the response scales used to measure information distortion might influence its constituent processes, limiting their generalizability across and beyond experimental studies

The frequency of missed test results and associated treatment delays in a highly computerized health system

<p>Abstract</p> <p>Background:</p> <p>Diagnostic errors associated with the failure to follow up on abnormal diagnostic studies ("missed results") are a potential cause of treatment delay and a threat to patient safety. Few data exist concerning the frequency of missed results and associated treatment delays within the Veterans Health Administration (VA).</p> <p>Objective:</p> <p>The primary objective of the current study was to assess the frequency of missed results and resulting treatment delays encountered by primary care providers in VA clinics.</p> <p>Methods:</p> <p>An anonymous on-line survey of primary care providers was conducted as part of the health systems ongoing quality improvement programs. We collected information from providers concerning their clinical effort (e.g., number of clinic sessions, number of patient visits per session), number of patients with missed abnormal test results, and the number and types of treatment delays providers encountered during the two week period prior to administration of our survey.</p> <p>Results:</p> <p>The survey was completed by 106 out of 198 providers (54 percent response rate). Respondents saw and average of 86 patients per 2 week period. Providers encountered 64 patients with missed results during the two week period leading up to the study and 52 patients with treatment delays. The most common missed results included imaging studies (29 percent), clinical laboratory (22 percent), anatomic pathology (9 percent), and other (40 percent). The most common diagnostic delays were cancer (34 percent), endocrine problems (26 percent), cardiac problems (16 percent), and others (24 percent).</p> <p>Conclusion:</p> <p>Missed results leading to clinically important treatment delays are an important and likely underappreciated source of diagnostic error.</p

What Was I Thinking? Eye-Tracking Experiments Underscore the Bias that Architecture Exerts on Nuclear Grading in Prostate Cancer

We previously reported that nuclear grade assignment of prostate carcinomas is subject to a cognitive bias induced by the tumor architecture. Here, we asked whether this bias is mediated by the non-conscious selection of nuclei that “match the expectation” induced by the inadvertent glance at the tumor architecture. 20 pathologists were asked to grade nuclei in high power fields of 20 prostate carcinomas displayed on a computer screen. Unknown to the pathologists, each carcinoma was shown twice, once before a background of a low grade, tubule-rich carcinoma and once before the background of a high grade, solid carcinoma. Eye tracking allowed to identify which nuclei the pathologists fixated during the 8 second projection period. For all 20 pathologists, nuclear grade assignment was significantly biased by tumor architecture. Pathologists tended to fixate on bigger, darker, and more irregular nuclei when those were projected before kigh grade, solid carcinomas than before low grade, tubule-rich carcinomas (and vice versa). However, the morphometric differences of the selected nuclei accounted for only 11% of the architecture-induced bias, suggesting that it can only to a small part be explained by the unconscious fixation on nuclei that “match the expectation”. In conclusion, selection of « matching nuclei » represents an unconscious effort to vindicate the gravitation of nuclear grades towards the tumor architecture

Stability of mRNA/DNA and DNA/DNA Duplexes Affects mRNA Transcription

Nucleic acids, due to their structural and chemical properties, can form double-stranded secondary structures that assist the transfer of genetic information and can modulate gene expression. However, the nucleotide sequence alone is insufficient in explaining phenomena like intron-exon recognition during RNA processing. This raises the question whether nucleic acids are endowed with other attributes that can contribute to their biological functions. In this work, we present a calculation of thermodynamic stability of DNA/DNA and mRNA/DNA duplexes across the genomes of four species in the genus Saccharomyces by nearest-neighbor method. The results show that coding regions are more thermodynamically stable than introns, 3′-untranslated regions and intergenic sequences. Furthermore, open reading frames have more stable sense mRNA/DNA duplexes than the potential antisense duplexes, a property that can aid gene discovery. The lower stability of the DNA/DNA and mRNA/DNA duplexes of 3′-untranslated regions and the higher stability of genes correlates with increased mRNA level. These results suggest that the thermodynamic stability of DNA/DNA and mRNA/DNA duplexes affects mRNA transcription

Use of inductive, problem-based clinical reasoning enhances diagnostic accuracy in final year veterinary students

Despite tremendous progression in the medical field, levels of diagnostic error remain unacceptably high. Cognitive failures in clinical reasoning are believed to be the major contributor to diagnostic error. There is evidence in the literature that teaching problem-based, inductive reasoning has the potential to improve clinical reasoning skills. In this study, 47 final-year veterinary medicine students at the Royal Veterinary College (RVC) were presented with a complex small animal medicine case. The participants were divided into two groups, one of which received a prioritized problem list in addition to the history, physical exam, and diagnostic test results provided to both groups. The students’ written approaches to the case were then analyzed and assigned a diagnostic accuracy score (DAS) and an inductive reasoning score (IRS). The IRS was based on a series of predetermined characteristics consistent with the inductive reasoning framework taught at the RVC. No significant difference was found between the DAS scores of each group, indicating that the provision of a prioritized problem list did not impact diagnostic accuracy. However, a significant positive correlation between the IRS and DAS was illustrated for both groups of students, suggesting increased use of inductive reasoning is associated with increased diagnostic accuracy. These results contribute to a body of research proposing that inductive, problem-based reasoning teaching delivered in an additive model, can enhance the clinical reasoning skills of students and reduce diagnostic error

Conscious thought beats deliberation without attention in diagnostic decision-making: at least when you are an expert

Contrary to what common sense makes us believe, deliberation without attention has recently been suggested to produce better decisions in complex situations than deliberation with attention. Based on differences between cognitive processes of experts and novices, we hypothesized that experts make in fact better decisions after consciously thinking about complex problems whereas novices may benefit from deliberation-without-attention. These hypotheses were confirmed in a study among doctors and medical students. They diagnosed complex and routine problems under three conditions, an immediate-decision condition and two delayed conditions: conscious thought and deliberation-without-attention. Doctors did better with conscious deliberation when problems were complex, whereas reasoning mode did not matter in simple problems. In contrast, deliberation-without-attention improved novices’ decisions, but only in simple problems. Experts benefit from consciously thinking about complex problems; for novices thinking does not help in those cases

Understanding the management of electronic test result notifications in the outpatient setting

<p>Abstract</p> <p>Background</p> <p>Notifying clinicians about abnormal test results through electronic health record (EHR) -based "alert" notifications may not always lead to timely follow-up of patients. We sought to understand barriers, facilitators, and potential interventions for safe and effective management of abnormal test result delivery via electronic alerts.</p> <p>Methods</p> <p>We conducted a qualitative study consisting of six 6-8 member focus groups (N = 44) at two large, geographically dispersed Veterans Affairs facilities. Participants included full-time primary care providers, and personnel representing diagnostic services (radiology, laboratory) and information technology. We asked participants to discuss barriers, facilitators, and suggestions for improving timely management and follow-up of abnormal test result notifications and encouraged them to consider technological issues, as well as broader, human-factor-related aspects of EHR use such as organizational, personnel, and workflow.</p> <p>Results</p> <p>Providers reported receiving a large number of alerts containing information unrelated to abnormal test results, many of which were believed to be unnecessary. Some providers also reported lacking proficiency in use of certain EHR features that would enable them to manage alerts more efficiently. Suggestions for improvement included improving display and tracking processes for critical alerts in the EHR, redesigning clinical workflow, and streamlining policies and procedures related to test result notification.</p> <p>Conclusion</p> <p>Providers perceive several challenges for fail-safe electronic communication and tracking of abnormal test results. A multi-dimensional approach that addresses technology as well as the many non-technological factors we elicited is essential to design interventions to reduce missed test results in EHRs.</p