The use of deliberate reflection to reduce confirmation bias among orthopedic surgery residents
Introduction: cognitive biases might affect decision-making processes such as clinical reasoning and confirmation bias is among the most important ones. The use of strategies that stimulate deliberate reflection during the diagnostic process seems to reduce availability bias, but its effect in reducing confirmation bias needs to be evaluated.
Aims: to examine whether deliberate reflection reduces confirmation bias and increases the diagnostic accuracy of orthopedic residents solving written clinical cases.
Methods: experimental study comparing the diagnostic accuracy of orthopedic residents in the resolution of eight written clinical cases containing a referral diagnosis. Half of the written cases had a wrong referral diagnosis. One group of residents used deliberate reflection (RG), which stimulates comparison and contrast of clinical hypotheses in a systematic manner, and a control group (CG), was asked to provide differential diagnoses with no further instruction. The study included 55 third-year orthopedic residents, 27 allocated to the RG and 28 to the CG.
Results: residents on the RG had higher diagnostic scores than the CG for clinical cases with a correct referral diagnosis (62.0±20.1 vs. 49.1±21.0 respectively; p = 0.021). For clinical cases with incorrect referral diagnosis, diagnostic accuracy was similar between residents on the RG and those on the CG (39.8±24.3 vs. 44.6±26.7 respectively; p = 0.662). We observed an overall confirmation bias in 26.3% of initial diagnoses (non-analytic phase) and 19.5% of final diagnoses (analytic phase) when solving clinical cases with incorrect referral diagnosis. Residents from RG showed a reduction in confirmation of incorrect referral diagnosis when comparing the initial diagnosis given in the non-analytic phase with the one provided as the final diagnosis (25.9±17.7 vs. 17.6±18.1, respectively; Cohen d: 0.46; p = 0.003). In the CG, the reduction in the confirmation of incorrect diagnosis was not statistically significant.
Conclusions: confirmation bias was present when residents solved written clinical cases with incorrect referral diagnoses, and deliberate reflection reduced such bias. Despite the reduction in confirmation bias, diagnostic accuracy of residents from the RG was similar to those from the CG when solving the set of clinical cases with a wrong referral diagnosis.
Evans JS. In two minds: dual-process accounts of reasoning. Trends Cogn Sci. 2003;7(10):454-9. http://dx.doi.org/10.1016%2Fj.tics.2003.08.012
Croskerry P. A universal model of diagnostic reasoning. Acad Med. 2009;84(8):1022-8. https://doi.org/10.1097/acm.0b013e3181ace703
Custers EJ. Medical education and cognitive continuum theory: an alternative perspective on medical problem solving and clinical reasoning. Acad Med. 2013;88(8):1074-80. https://doi.org/10.1097/acm.0b013e31829a3b10
Mamede S, Schmidt HG, Rikers RM, Custers EJ, Splinter TA, van Saase JL. Conscious thought beats deliberation without attention in diagnostic decision-making: at least when you are an expert. Psychol Res. 2010;74(6):586-92. https://doi.org/10.1007/s00426-010-0281-8
Casali MB, Blandino A, Del Sordo S, Vignali G, Novello S, Travaini G. et al. Alleged malpractice in orthopaedics. Analysis of a series of medmal insurance claims. J Orthop Traumatol. 2018;27;19(1):7. https://doi.org/10.1186/s10195-018-0500-4
Ng VCN, Lau FL. A retrospective review of patients with radiological missed fractures in an emergency department in Hong Kong. Hong Kong Journal of Emergency Medicine 2003;10(4):215-22. https://doi.org/10.1177%2F102490790301000403
Graber M, Gordon R, Franklin N. Reducing diagnostic errors in medicine: what's the goal? Acad Med. 2002;77(10):981-92. https://doi.org/10.1097/00001888-200210000-00009
Croskerry P. Cognitive forcing strategies in clinical decision making. Ann Emerg Med. 2003;41(1):110-20. https://doi.org/10.1067/mem.2003.22
van den Berge K, Mamede S. Cognitive diagnostic error in internal medicine. Eur J Intern Med. 2013;24(6):525-9. https://doi.org/10.1016/j.ejim.2013.03.006
Hartigan S, Brooks M, Hartley S, Miller RE, Santen SA, Hemphill RR. Review of the basics of cognitive error in emergency medicine: Still No Easy Answers. West J Emerg Med. 2020;21(6):125-131. https://doi.org/10.5811/westjem.2020.7.47832
Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005 Jul 11;165(13):1493-9. https://doi.org/10.1001/archinte.165.13.1493
Klayman J. Varieties of confirmation bias. The Psychology of learning and motivation 1995;32:385-418. https://doi.org/10.1016/S0079-7421(08)60315-1
Croskerry P, Norman G. Overconfidence in clinical decision making. Am J Med. 2008;121(5 Suppl): S24-9. https://doi.org/10.1016/j.amjmed.2008.02.001
Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-80. https://doi.org/10.1097/00001888-200308000-00003
Lighthall GK, Vazquez-Guillamet C. Understanding decision making in critical care. Clin Med Res. 2015;13(3-4):156-68. https://doi.org/10.3121/cmr.2015.1289
Croskerry P, Singhal G, Mamede S. Cognitive debiasing 2: impediments to and strategies for change. BMJ Qual Saf. 2013;2(S2):65-72. http://dx.doi.org/10.1136/bmjqs-2012-001713
Mamede S, van Gog T, van den Berge K, Rikers RM, van Saase JL, van Guldener C. et al. Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents. JAMA. 2010;304(11):1198-203. https://doi.org/10.1001/jama.2010.1276
Mamede S, Carvalho-Filho MA, Faria RMD, Franci D, Nunes MPT, Ribeiro LMC. et al. ‘Immunising’ physicians against availability bias in diagnostic reasoning: a randomised controlled experiment. BMJ Quality & Safety 2020; 29:550-9. http://dx.doi.org/10.1136/bmjqs-2019-010079
Ibiapina C, Mamede S, Moura A, Elói-Santos S, van Gog T. Effects of free, cued and modelled reflection on medical students' diagnostic competence. Med Educ. 2014;48(8):796-805. https://doi.org/10.1111/medu.12435
Ribeiro LMC, Mamede S, Brito EM, Moura AS, Faria RMD, Schmidt HG. Effects of deliberate reflection on students' engagement in learning and learning outcomes. Med Educ. 2019;53(4):390-7. https://doi.org/10.1111/medu.13798
Sherbino J, Kulasegaram K, Howey E, Norman G. Ineffectiveness of cognitive forcing strategies to reduce biases in diagnostic reasoning: a controlled trial. CJEM. 2014;16(1):34-40. https://doi.org/10.2310/8000.2013.130860
O'Sullivan ED, Schofield SJ. A cognitive forcing tool to mitigate cognitive bias - a randomised control trial. BMC Med Educ. 2019;19(1):12. https://doi.org/10.1186/s12909-018-1444-3
Mamede S, van Gog T, Moura AS, Faria RM, Peixoto JM, Rikers RM et al. Reflection as a strategy to foster medical students' acquisition of diagnostic competence. Med Educ. 2012;46(5):464-72. https://doi.org/10.1111/j.1365-2923.2012.04217.x
Costa Filho GB, Moura AS, Brandão PR, Schmidt HG, Mamede S. Effects of deliberate reflection on diagnostic accuracy, confidence and diagnostic calibration in dermatology. Perspect Med Educ. 2019;8(4):230-6. https://doi.org/10.1007/s40037-019-0522-5
Mamede S, Figueiredo-Soares T, Santos SME, Faria RMD, Schmidt HG, van Gog T. Fostering novive students’ diagnosis ability: the value of guiding deliberate reflection. Med Educ. 2019;53(6):628-37. https://doi.org/10.1111/medu.13829
Mamede S. What does research on clinical reasoning have to say to clinical teachers? Sci Med, 2020;30:1-8. https://doi.org/10.15448/1980-6108.2020.1.37350
Eva KW. What every teacher needs to know about clinical reasoning. Med Educ. 2005;39(1):98-106. https://doi.org/10.1111/j.1365-2929.2004.01972.x
Schmidt HG, Mamede S. How to improve the teaching of clinical reasoning: a narrative review and a proposal. Med Educ. 2015;49(10):961-73. https://doi.org/10.1111/j.1365-2929.2004.01972.x
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