Abstract
BackgroundCognitive dispositions to respond (i.e., cognitive biases and heuristics) are well-established clinical reasoning phenomena. While thought by many to be error-prone, some scholars contest that these cognitive dispositions to respond are pragmatic solutions for reasoning through clinical complexity that are associated with errors largely due to hindsight bias and flawed experimental design. The purpose of this study was to prospectively identify cognitive dispositions to respond occurring during clinical reasoning to determine whether they are actually associated with increased odds of an incorrect answer (i.e., error).MethodsUsing the cognitive disposition to respond framework, this mixed-methods study applied a constant comparative qualitative thematic analysis to transcripts of think alouds performed during completion of clinical-vignette multiple-choice questions. The number and type of cognitive dispositions to respond associated with both correct and incorrect answers were identified. Participants included medical students, residents, and attending physicians recruited using maximum variation strategies. Data were analyzed using generalized estimating equations binary logistic model for repeated, within-subjects measures.ResultsAmong 14 participants, there were 3 cognitive disposition to respond categories – Cognitive Bias, Flaws in Conceptual Understanding, and Other Vulnerabilities – with 13 themes identified from the think aloud transcripts. The odds of error increased to a statistically significant degree with a greater per-item number of distinct Cognitive Bias themes (OR = 1.729, 95% CI [1.226, 2.437], p = 0.002) and Other Vulnerabilities themes (OR = 2.014, 95% CI [1.280, 2.941], p < 0.001), but not with Flaws in Conceptual Understanding themes (OR = 1.617, 95% CI [0.961, 2.720], p = 0.070).ConclusionThis study supports the theoretical understanding of cognitive dispositions to respond as phenomena associated with errors in a new prospective manner. With further research, these findings may inform teaching, learning, and assessment of clinical reasoning toward a reduction in patient harm due to clinical reasoning errors.
Highlights
Cognitive dispositions to respond are well-established clinical reasoning phenomena
146 (69.5%) Multiple Choice Question (MCQ) items were answered correctly by participants in this study, compared to expected performance of approximately 64% correct based on Medical Knowledge Self-Assessment Program (MKSAP) data
For each additional distinct Cognitive Bias cognitive dispositions to respond (CDRs) and Other Vulnerability CDR present in a single case in our study sample, the findings suggest the odds of committing an error increases by a magnitude of approximately two-fold – similar to the increased risk for error conferred by being a trainee compared to being an attending physician
Summary
Cognitive dispositions to respond (i.e., cognitive biases and heuristics) are well-established clinical reasoning phenomena. The purpose of this study was to prospectively identify cognitive dispositions to respond occurring during clinical reasoning to determine whether they are associated with increased odds of an incorrect answer (i.e., error). Despite the tremendous personal and public health burdens of diagnostic error, there has been relative inattention directed towards understanding and reducing it [3]. This may be due to a number of factors inherent to diagnostic errors, including difficulty in defining and identifying them, their subjective nature, delays in recognizing them, their complex and multifactorial causation [6, 7], and the lack of clear solutions [8]. The current healthcare delivery system cultivates “a culture that discourages transparency and disclosure of diagnostic errors—impeding attempts to learn from these events and improve diagnosis,” [3] preventing clinicians and institutions from receiving the feedback from real-world clinical practice necessary to improve diagnostic reliability [9]
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