Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents.
BACKGROUND
Diagnostic errors have been associated with bias in clinical reasoning. Empirical evidence on the cognitive mechanisms underlying biases and effectiveness of educational strategies to counteract them is lacking.


OBJECTIVE
To investigate whether recent experience with clinical problems provokes availability bias (overestimation of the likelihood of a diagnosis based on the ease with which it comes to mind) resulting in diagnostic errors and whether reflection (structured reanalysis of the case findings) counteracts this bias.


METHODS
Experimental study conducted in 2009 at the Erasmus Medical Centre, Rotterdam, with 18 first-year and 18 second-year internal medicine residents. Participants first evaluated diagnoses of 6 clinical cases (phase 1). Subsequently, they diagnosed 8 different cases through nonanalytical reasoning, 4 of which had findings similar to previously evaluated cases but different diagnoses (phase 2). These 4 cases were subsequently diagnosed again through reflective reasoning (phase 3).


METHODS
Mean diagnostic accuracy scores (perfect score, 4.0) on cases solved with or without previous exposure to similar problems through nonanalytical (phase 2) or reflective (phase 3) reasoning and frequency that a potentially biased (ie, phase 1) diagnosis was given.


RESULTS
There were no main effects, but there was a significant interaction effect between "years of training" and "recent experiences with similar problems." Results consistent with an availability bias occurred for the second-year residents, who scored lower on the cases similar to those previously encountered (1.55; 95% confidence interval [CI], 1.15-1.96) than on the other cases (2.19; 95% CI, 1.73-2.66; P =.03). This pattern was not seen among the first-year residents (2.03; 95% CI, 1.55-2.51 vs 1.42; 95% CI, 0.92-1.92; P =.046). Second-year residents provided the phase 1 diagnosis more frequently for phase 2 cases they had previously encountered than for those they had not (mean frequency per resident, 1.44; 95% CI, 0.93-1.96 vs 0.72; 95% CI, 0.28-1.17; P =.04). A significant main effect of reasoning mode was found: reflection improved the diagnoses of the similar cases compared with nonanalytical reasoning for the second-year residents (2.03; 95% CI, 1.49-2.57) and the first-year residents (2.31; 95% CI, 1.89-2.73; P =.006).


CONCLUSIONS
When faced with cases similar to previous ones and using nonanalytic reasoning, second-year residents made errors consistent with the availability bias. Subsequent application of diagnostic reflection tended to counter this bias; it improved diagnostic accuracy in both first- and second-year residents.
Mamede
Sílvia
S
Department of Psychology, Erasmus University Rotterdam, Burgemeester Oudlaan 50, Rotterdam, 3062 PA, The Netherlands. mamede@fsw.eur.nl
van Gog
Tamara
T
van den Berge
Kees
K
Rikers
Remy M J P
RM
van Saase
Jan L C M
JL
van Guldener
Coen
C
Schmidt
Henk G
HG
D003071:Cognition; D003951:Diagnostic Errors; D003955:Diagnostic Tests, Routine; D006801:Humans; D007388:Internal Medicine / Q000193:education*; D007396:Internship and Residency; D009426:Netherlands; D015588:Observer Variation; D010808:Physical Examination