Specific Disease Knowledge as Predictor of Susceptibility to Availability Bias in Diagnostic Reasoning: a Randomized Con
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Institute of Medical Education Research Rotterdam, Erasmus MC, University Medical Centre Rotterdam Rotterdam, The Netherlands; 2Department of Psychology, Education & Child Studies, Erasmus University Rotterdam Rotterdam, The Netherlands; 3Department of Internal Medicine, Erasmus Medical Center Rotterdam, The Netherlands; 4Centre for Educational Research and Development in Health Professions, University Medical Centre Groningen, The Netherlands; 5Internal Medicine Department, School of Medical Sciences, State University of Campinas Campinas, Brazil.
BACKGROUND: Bias in reasoning rather than knowledge gaps has been identified as the origin of most diagnostic errors. However, the role of knowledge in counteracting bias is unclear. OBJECTIVE: To examine whether knowledge of discriminating features (findings that discriminate between lookalike diseases) predicts susceptibility to bias. DESIGN: Three-phase randomized experiment. Phase 1 (bias-inducing): Participants were exposed to a set of clinical cases (either hepatitis-IBD or AMI-encephalopathy). Phase 2 (diagnosis): All participants diagnosed the same cases; 4 resembled hepatitis-IBD, 4 AMI-encephalopathy (but all with different diagnoses). Availability bias was expected in the 4 cases similar to those encountered in phase 1. Phase 3 (knowledge evaluation): For each disease, participants decided (max. 2 s) which of 24 findings was associated with the disease. Accuracy of decisions on discriminating features, taken as a measure of knowledge, was expected to predict susceptibility to bias. PARTICIPANTS: Internal medicine residents at Erasmus MC, Netherlands. MAIN MEASURES: The frequency with which higherknowledge and lower-knowledge physicians gave biased diagnoses based on phase 1 exposure (range 0–4). Time to diagnose was also measured. KEY RESULTS: Sixty-two physicians participated. Higher-knowledge physicians yielded to availability bias less often than lower-knowledge physicians (0.35 vs 0.97; p = 0.001; difference, 0.62 [95% CI, 0.28–0.95]). Whereas lower-knowledge physicians tended to make more of these errors on subjected-to-bias than on not-subjected-to-bias cases (p = 0.06; difference, 0.35 [CI, − 0.02–0.73]), higherknowledge physicians resisted the bias (p = 0.28). Both groups spent more time to diagnose subjected-to-bias than not-subjected-to-bias cases (p = 0.04), without differences between groups.
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11606-020-06182-6) contains supplementary material, which is available to authorized users. Received March 27, 2020 Accepted August 24, 2020
CONCLUSIONS: Knowledge of features that discriminate between look-alike diseases reduced susceptibility to bias in a simulated setting. Reflecting further may be required to overcome bias, but succeeding depends on having the appropriate knowledge. Future research should examine whether the findings apply to real practice and to more experienced physicians. KEY WORDS: diagnostic error; availability bias; diagnostic reasoning;
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