Seen through their eyes:  residents' reflections on the cognitive and contextual components of diagnostic errors in medicine.
OBJECTIVE
Diagnostic errors in medicine are common and costly. Cognitive bias causes are increasingly recognized contributors to diagnostic error but remain difficult targets for medical educators and patient safety experts. The authors explored the cognitive and contextual components of diagnostic errors described by internal medicine resident physicians through the use of an educational intervention.


METHODS
Forty-one internal medicine residents at University of Pennsylvania participated in an educational intervention in 2010 that comprised reflective writing and facilitated small-group discussion about experiences with diagnostic error from cognitive bias. Narratives and discussion were transcribed and analyzed iteratively to identify types of cognitive bias and contextual factors present.


RESULTS
All residents described a personal experience with a case of diagnostic error that contained at least one cognitive bias and one contextual factor that may have influenced the outcome. The most common cognitive biases identified by the residents were anchoring bias (36; 88%), availability bias (31; 76%), and framing effect (23; 56%). Prominent contextual factors included caring for patients on a subspecialty service (31; 76%), complex illness (26; 63%), and time pressures (22; 54%). Eighty-five percent of residents described at least one strategy to avoid a similar error in the future.


CONCLUSIONS
Residents can easily recall diagnostic errors, analyze the errors for cognitive bias, and richly describe their context. The use of reflective writing and narrative discussion is an educational strategy to teach recognition, analysis, and cognitive-bias-avoidance strategies for diagnostic error in residency education.
Division of Rheumatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA. alexis.ogdie@uphs.upenn.edu
Alexis R
AR
Ogdie
James B
JB
Reilly
Wyki G
WG
Pang
Shimrit
S
Keddem
Frances K
FK
Barg
Joan M
JM
Von Feldt
Jennifer S
JS
Myers
D001291:Attitude of Health Personnel; D003071:Cognition; D003479:Curriculum; D003951:Diagnostic Errors / Q000517:prevention & control / Q000523:psychology*; D005260:Female; D006126:Group Processes; D006801:Humans; D007388:Internal Medicine / Q000193:education*; D007396:Internship and Residency; D008297:Male; D010414:Pennsylvania; D010820:Physicians / Q000523:psychology*; D011287:Prejudice; D013997:Time Factors; D014956:Writing