Bias In Clinical Practice Research Articles

Understanding AI bias in clinical practice

Understanding AI bias in clinical practice

Gender Bias Existence: A Qualitative Exploration of Dental Students’ Perception of the Impact of their Gender on Learning in Clinical Practice

Introduction: Gender bias in clinical practice is a topic that has received increasing attention in recent years; however, little is known about how dental students perceive and experience gender bias in their training.Objective: To explore dental students' perceptions regarding the existence of gender bias and the impact of their gender on their learning in clinical practice.Methods: The qualitative exploratory research design was used to conduct this study using semi-structured interviews. Data was collected from a diverse group of 15 undergraduate dental students at different stages of their studies. Interviews were transcribed and analysed to form themes.Results: Dental students perceive that there is a vital role for gender in the mentorship they receive in clinical practice and learning opportunities.Conclusion: Spreading awareness of gender bias during undergraduate programmes can help supervisors focus on its effects and find ways to reduce it. These findings highlight the need for urgent attention to gender bias in dental education and the importance of creating a fair, just, and inclusive learning environment for all students.Keywords: Gender Bias, Stereotype, Gender, Dental Student, Clinical Learning

Gender and sex bias in prevention and clinical treatment of women's chronic pain: hypotheses of a curriculum development.

This discursive paper focuses on undergraduate medical education's role in tackling gender bias in clinical practice, specifically preventing and managing from a non-biomedical perspective chronic pain in women. A preliminary web search of medical schools' curricula was performed to identify programs content related to gender bias in pain management. The web search included 10 universities' websites selected from the top 10 rankings QS Universities Rankings 2022 for medical schools. Additionally, a questionnaire was sent to all deans of the selected academic institutions to explore the curriculum content further. The web search, and the lack of response from the deans, highlighted that relevant curriculum components on gender bias and chronic pain needed to be implemented. Therefore, this paper introduces an innovative curriculum development approach designed by the multi-professional research team to be implemented in medical school programs. This novel educational strategy could also cross-contaminate other healthcare practitioners' university programs and, thus, stimulate an interprofessional debate into fostering inclusiveness and equal opportunities in health.

“RVUS”: A Structured Framework for Residents to Approach Bias in Clinical Practice (S13.005)

<h3>Objective:</h3> To enhance resident education on racism and all forms of discrimination in the healthcare setting using a case-based curriculum. <h3>Background:</h3> The level of interest in addressing racism and ethnic inequality in medicine has risen dramatically in recent decades, with increasing awareness of the close relationship between racial injustice and healthcare disparities. Despite the acknowledged importance of addressing racism and topics of diversity, equity, and inclusion at large, implementation of formal education around these topics has been mixed or absent, with no universal requirements for such training at residency/fellowship levels. <h3>Design/Methods:</h3> We developed a year-long curriculum consisting of 12 case-based monthly discussions between residents and faculty. The cases are designed to be interactive sessions, 15–20 minutes long, each covering a different type of bias, from macroaggressions to the varieties of microaggressions. Each encounter focuses on a different topic regarding diversity, equity and inclusion. The series is presented by residents to co-residents. A novel learning tool “RVUS” was devised to systematically approach each case with R standing for recognizing the problem, V for validating the feelings of the person(s) experiencing prejudice, U for unpacking the underlying elements leading to the situation, and S for solutions or suggestions to resolve the matter. <h3>Results:</h3> We finished our pilot year (2021–2022) and started our first formal year in July 2022. Preliminary results from anonymous survey suggests that outside of developing skills, having formal, safe, educational sessions dedicated to diversity and discrimination has helped participants feel more comfortable discussing and addressing these scenarios, creating an environment where they are able to learn from each other and share their own experiences in the process. <h3>Conclusions:</h3> Dedicated resident education to help combat discrimination, address microaggressions, and foster health equity, diversity, and inclusion can be achieved through a case-based curriculum especially when combined with a systematic approach such as RVUS. <b>Disclosure:</b> Dr. Yu has nothing to disclose. Dr. Elfasi has nothing to disclose. Dr. Figueredo Rivas has nothing to disclose. Dr. Hernandez has nothing to disclose. Dr. Bruzzone has nothing to disclose.

Development of an instrument to measure awareness and mitigation of bias in maternal healthcare.

Implicit bias among maternal healthcare professionals contributes to disrespectful care and racial and ethnic disparities in patient outcomes, and there is growing consensus that implicit bias training is a key component of birth equity initiatives. A requirement for implicit bias training for healthcare professionals has become more widespread, but the impact training has is largely unknown, in part, because of a lack of validated instruments. Therefore, there is an urgent need for a psychometrically valid instrument for use in the evaluation of implicit bias training. This study aimed to develop a valid and reliable instrument to assess implicit bias awareness and mitigation practices among maternal care professionals and that can be used to evaluate interventions aimed at mitigating such bias in clinical practice. We conducted an instrument development and validation study in 3 phases. In phase 1, item development, we generated a 43-item bank from literature and consultation and established content validity with subject matter experts. In phase 2, instrument development, we administered a revised set of 33 items to 307 nurses and midwives and conducted exploratory factor analysis to demonstrate construct validity and reliability. In phase 3, instrument evaluation, we confirmed the factor structure and compared the means of implicit bias training-exposed and -unexposed participants to further demonstrate construct validity with a representative state sample of 2096 maternal healthcare professionals (physicians, midwives, and nurses). Based on phase 2 results, we retained 23 items for the Bias in Maternal Health Care scale, which showed high internal consistency (Cronbach's alpha, 0.86). We identified 3 subscales, namely a 9-item Bias Awareness subscale (Cronbach's alpha, 0.86), a 7-item Bias Mitigation Practice subscale (Cronbach's alpha, 0.82), and a 7-item Bias Mitigation Self-Efficacy subscale (Cronbach's alpha, 0.81). Validation of the Bias Awareness and Bias Mitigation Practice subscales in phase 3 demonstrated the instrument's high reliability (Cronbach's alpha 0.86 and 0.83, respectively) and discriminating performance among maternal healthcare professionals. We developed a reliable and valid instrument for measuring awareness and mitigation of bias among maternal healthcare professionals. It can be used to evaluate implicit bias training and other bias mitigation interventions in maternal healthcare settings.

Reflexivity as a tool for medical students to identify and address gender bias in clinical practice: A qualitative study

ObjectivesGender bias interferes with medical care for both men and women, leading to health inequalities. Reflexivity is used in medical education to improve health provision. This study aims to understand if a reflective approach integrated in medical practice enables raising awareness of gender bias during medical school teaching. MethodsWe conducted this study in general ambulatory medicine in Lausanne Hospital, Switzerland with 160 Master’s students. Through group discussions and reflection questionnaires, students were asked to discuss clinical cases they encountered focusing on potential gender bias. We analyzed the data using a thematic analysis approach. ResultsThe reflection on the clinical reasoning steps from a real case identified gender bias at each stage of the clinical case management. The analysis revealed two factors that facilitated gender reflexivity: guidance from a gender expert and peer-to-peer exchange. ConclusionsOur study shows that a reflective approach integrated in medical practice enables raising awareness of gender bias during medical teaching. It provides students with a systematic method they can apply in their future clinical work, thus improving care processes and experiences towards more equitable care. Practice implicationsAll gender and medicine curricula should include teaching such as this linking theory and practice through reflexivity.

The reduction of race and gender bias in clinical treatment recommendations using clinician peer networks in an experimental setting

Bias in clinical practice, in particular in relation to race and gender, is a persistent cause of healthcare disparities. We investigated the potential of a peer-network approach to reduce bias in medical treatment decisions within an experimental setting. We created “egalitarian” information exchange networks among practicing clinicians who provided recommendations for the clinical management of patient scenarios, presented via standardized patient videos of actors portraying patients with cardiac chest pain. The videos, which were standardized for relevant clinical factors, presented either a white male actor or Black female actor of similar age, wearing the same attire and in the same clinical setting, portraying a patient with clinically significant chest pain symptoms. We found significant disparities in the treatment recommendations given to the white male patient-actor and Black female patient-actor, which when translated into real clinical scenarios would result in the Black female patient being significantly more likely to receive unsafe undertreatment, rather than the guideline-recommended treatment. In the experimental control group, clinicians who were asked to independently reflect on the standardized patient videos did not show any significant reduction in bias. However, clinicians who exchanged real-time information in structured peer networks significantly improved their clinical accuracy and showed no bias in their final recommendations. The findings indicate that clinician network interventions might be used in healthcare settings to reduce significant disparities in patient treatment.

Solving gender gaps in health, what else is missing?

In recent years, a great deal of attention has been paid to gender inequities in health. However, while we have a good body of evidence on the impact of gender on the health and vulnerability of women and men, we have not yet been able to generate sufficient evidence on effective interventions that can transform this situation or can influence public health policy making. Only a limited number of educational interventions on gender-sensitivity, gender bias in clinical practice and policies to tackle gender inequalities in health have been formulated, implemented and evaluated. Even in the current pandemic situation caused by SARS-CoV2, we have seen the lack of gender mainstreaming reflected in the global response. This happens even when we have tools that facilitate the formulation and implementation of actions to reduce gender inequities in health. We consider that the current initiatives organized to carry out advocacy activities on gender inequity in health to be very positive. In the same line of these initiatives, we propose that while academic and institutional research on gender and health remains essential, we need to shift the focus towards action. In order to move forward, we need public health researchers questioning what public health practice need to do to address gender inequities and shake structural and social power inequities in order to increase the gender equity in health.

THE MONEY IS IN THE AIRWAY: AN ATYPICAL CASE OF NON-CARDIAC CHEST PAIN

TOPIC: Signs and Symptoms of Chest Diseases TYPE: Fellow Case Reports INTRODUCTION: Foreign body aspiration is a common pathology in pediatric medicine but relatively infrequent in the adult population. Symptoms are usually those of acute airway irritation, including cough, dyspnea, and asphyxiation. Acute chest pain is an uncommon manifestation of foreign body aspiration and one that may be overlooked if history suggests another leading diagnosis. It is critical to avoid such a confounding bias, as anchoring can lead to adverse patient outcomes. CASE PRESENTATION: A 58-year-old man with diabetes mellitus, hypertension, coronary artery disease, and a history of substance abuse presented to the emergency department (ED) complaining of chest pain. He described a mid-chest pain that started after consuming cocaine. The pain was non-radiating but associated with mild shortness of breath. In the ED, he was tachycardic, hypertensive, and with normal saturation at room air. His EKG showed sinus tachycardia, and the laboratory workup was unremarkable. Chest X-Ray (fig.1) showed a round metallic density over the left mid lung. Chest CT scan (fig.2 and 3) showed a hyperattenuating foreign body within the left mainstem bronchus. He underwent a bronchoscopy in the operating room, and a dime was retrieved from the left mainstem bronchus with forceps. He tolerated the procedure well with no complications or airway injury and discharged home in stable condition. DISCUSSION: Despite the unusual times we have been going through due to the COVID-19 pandemic, ischemic heart disease remained the leading cause of death in the United States during 2020(1). It is well established that the abuse of illicit substances such as cocaine could lead to myocardial ischemia and infarction (2). Thus, it is a top differential diagnosis when a patient arrives in the ED with chest pain after cocaine use.It is well documented how premature closure and anchoring bias could negatively impact clinical outcomes (3,4,5). Hence, a thorough history and differential diagnosis are paramount to guide the workup and management. Cases of foreign body aspiration in adults often happen in the setting of altered mental status (6) or acute intoxication where patients rarely recall further details leading to their onset of symptoms. Still, the typical presentation includes cough and dyspnea (7) rather than chest pain.In a case of patient-reported recent cocaine use with subsequent chest pain, anchoring to a cocaine-induced chest pain diagnosis is at first understandable. It was the chest pain diagnostic workup that included a chest x-ray that found the cause that was not initially suspected. CONCLUSIONS: We present an interesting case of a dime aspiration lodging the left mainstem bronchus, who presented with chest pain after consuming cocaine. The lack of classic respiratory symptoms and the recent intoxication could have led to anchoring bias where the foreign body aspiration might have been overlooked. REFERENCE #1: 1. Ahmad FB, Cisewski JA, Minino A et al. Provisional Mortality Data – United States, 2020. MMWR Morb Mortal Wkly Rep 2021;70:519-522. REFERENCE #2: 2. McCord J, Jneid H, Hollander JE et al. Management of Cocaine-associated chest pain and myocardial infarction. Circulation. 2008;117:1897–1907. REFERENCE #3: 3. Khadilkar, S.V., Khadilkar, S.S. Bias in Clinical Practice. J Obstet Gynecol India 2020. 70, 1–5. https://doi.org/10.1007/s13224-019-01304-5 4. Makary MA, Daniel M. Medical error – the third leading cause of death in the US BMJ 2016;353:I2139 doi:10.1136/bmj.i2139 5. Saposnik, G., Redelmeier, D., Ruff, C. et al. Cognitive biases associated with medical decisions: a systematic review. BMC medical informatics and decision making, 2016(1), 138. https://doi.org/10.1186/s12911-016-0377-16. Ozdemir et al. Foreign Body Aspiration in Adult. Eurasian J Pulmonol 2015;17: 29-34 7. Bajaj et al. Foreign Body aspiration. J Thorac Dis 2020. doi: 10.21037/jtd.2020.03.94 DISCLOSURES: No relevant relationships by Israel Acosta Sanchez, source=Web Respons No relevant relationships by Tirsa Ferrer Marrero, source=Web Response No relevant relationships by Ray Urban, source=Web Response

NP student encounters with obesity bias in clinical practice.

This study explores NP students' encounters with obesity stigma and bias in their clinical environment as well as recommendations to decrease obesity stigma and bias. Results indicate a need for continued education on the topic of weight management within NP curricula.

Implicit attentional bias for facial emotion in dissociative seizures: Additional evidence

This study sought to extend knowledge about the previously reported preconscious attentional bias (AB) for facial emotion in patients with dissociative seizures (DS) by exploring whether the finding could be replicated, while controlling for concurrent anxiety, depression, and potentially relevant cognitive impairments. Patients diagnosed with DS (n=38) were compared with healthy controls (n=43) on a pictorial emotional Stroop test, in which backwardly masked emotional faces (angry, happy, neutral) were processed implicitly. The group with DS displayed a significantly greater AB to facial emotion relative to controls; however, the bias was not specific to negative or positive emotions. The group effect could not be explained by performance on standardized cognitive tests or self-reported depression/anxiety. The study provides additional evidence of a disproportionate and automatic allocation of attention to facial affect in patients with DS, including both positive and negative facial expressions. Such a tendency could act as a predisposing factor for developing DS initially, or may contribute to triggering individuals' seizures on an ongoing basis. Psychological interventions such as Cognitive Behavioral Therapy (CBT) or AB modification might be suitable approaches to target this bias in clinical practice.

To err is human: A case-based review of cognitive bias and its role in clinical decision making

To err is human: A case-based review of cognitive bias and its role in clinical decision making

People with a body mass index ⩾30 under-report their dietary intake: A systematic review.

Under-reporting of total energy intake is a common and well-known source of measurement error in dietary assessment, and evidence suggests that this bias is particularly significant in obese individuals. After a multi-stage selection process of eligible papers, this literature review appraised 34 papers detailing the accuracy of self-reported dietary intake in people with an obese body mass index (BMI ⩾ 30). The available literature to date shows that having a body mass index ⩾30 is associated with significant under-reporting of food intake. Future research should look into identifying effective techniques to reduce this bias in clinical practice.

Recognizing and reducing cognitive bias in clinical and forensic neurology.

In medicine, cognitive errors form the basis of bias in clinical practice. Several types of bias are common and pervasive, and may lead to inaccurate diagnosis or treatment. Forensic and clinical neurology, even when aided by current technologies, are still dependent on cognitive interpretations, and therefore prone to bias. This article discusses 4 common biases that can lead the clinician astray. They are confirmation bias (selective gathering of and neglect of contradictory evidence); base rate bias (ignoring or misusing prevailing base rate data); hindsight bias (oversimplification of past causation); and good old days bias (the tendency for patients to misremember and exaggerate their preinjury functioning). We briefly describe strategies adopted from the field of psychology that could minimize bias. While debiasing is not easy, reducing such errors requires awareness and acknowledgment of our susceptibility to these cognitive distortions.

Comorbidity, stigma and emotional perception in psychiatric disorders

Schizophrenia is associated with significant comorbidity and mortality—patients seemingly suffer more often from type-2 diabetes mellitus, diabetogenic complications plus environmentally influenced conditions than non-schizophrenic patients. Schoepf et al. [1] in a 12-year follow-up study with 1,418 adult schizophrenic patients and 14,180 ageand gender-matched hospital controls compared whether comorbidities with somatic diseases in fact lead to higher mortality. They discovered many of them to be more prevalent plus associated with a worse outcome in the schizophrenia population, whereas these patients suffered less from hypertension, hyperlipidemia, angina and cataract than controls. In the end, except parkinsonism the hospital mortality due to comorbid physical diseases did not significantly differ from the control population. Parkinsonism, again, was significantly prevalent in deceased schizophrenic patients compared to those surviving the study period. Anyhow, the authors recommend to thoroughly monitor and manage the most prevalent comorbidities in schizophrenia. Since there is an overlap between affective and schizophrenia symptoms in a large group of patients, Wilson et al. [2] critically question the reliability and clinical utility of the diagnosis of schizoaffective disorder after finding statistically significant deviances between clinical and research diagnoses in 134 psychiatric inpatients: While the treating clinicians had diagnosed 48 of these patients with schizophrenia, 50 with schizoaffective disorder and 36 with psychotic bipolar disorder, trained research personal again using the Structured Clinical Interview of the DSM-IV-TR inclusive an explicit time threshold for criterion C diagnosed 64 patients with schizophrenia, 38 with schizoaffective disorder and 32 with psychotic bipolar disorder. The authors assume a tendency for less severe diagnoses on clinician side and advocate a more stringent criterion C for the diagnosis schizoaffective disorder to address an implicit bias in clinical practice, which in the end might affect the prevalence of the psychotic disorder diagnoses. Only few studies so far have broached the issue of disempowerment and stigma-related stress in patients with mental illness due to involuntary hospitalization. Rusch et al. [3] assessed shame and self-contempt, self-stigma, empowerment, quality of life and self-esteem in 186 seriously mentally ill persons. Self-stigma was significantly associated with higher stigma stress levels independent of psychiatric symptoms, diagnosis, age, gender or the number of involuntary hospitalizations during lifetime inducing a negative effect on quality of life and empowerment. Thus, emotional reactions and stigma as a stressor should be considered in interventions to reduce the negative effects of compulsory measures. In an fMRI study with 18 female patients with a diagnosis of borderline personality disorder and 18 healthy female controls, Scherpiet et al. [4] investigated whether not only the perception of emotional stimuli but also the mere anticipation of upcoming emotional pictures leads to emotional dysregulation associated with the disorder. Compared to controls, the patient sample showed deficient recruitment of various brain areas related to cognitiveemotional interaction already in the anticipation phase of both negative and ambiguously announced stimuli possibly adding to the emotional dysregulation and contributing to hypersensitivity toward emotional cues. Emotional perception is also subject of Schonenberg and Jusytes [5] A. Schmitt (&) P. Falkai Department of Psychiatry and Psychotherapy, LudwigMaximilians-University Munich, Nusbaumstr. 7, 80336 Munich, Germany e-mail: Andrea.Schmitt@med.uni-muenchen.de

The schizoaffective disorder diagnosis: a conundrum in the clinical setting.

The term schizoaffective was introduced to describe the co-occurrence of both psychotic and affective symptoms. Overtime, as the diagnosis schizoaffective disorder was added to diagnostic manuals, significant concerns were raised as to the reliability and clinical utility of the diagnosis. We recruited 134 psychiatrically hospitalized subjects who had received a diagnosis of schizophrenia, schizoaffective disorder or bipolar disorder with psychotic features by their treating clinician. The subjects were also diagnosed by trained research personnel with the Structured Clinical Interview of the DSM-IV-TR, employing an explicit time threshold for criterion C of the schizoaffective disorder diagnosis. We found significant differences between the clinical and research diagnoses. Clinicians diagnosed 48 patients (36%) with schizophrenia, 50 patients (37%) with schizoaffective disorder and 36 patients (27%) with psychotic bipolar disorder. In contrast, researchers diagnosed 64 patients (48%) with schizophrenia, 38 patients (28%) with schizoaffective disorder and 32 patients (24%) with psychotic bipolar disorder. This was a statistically significant disagreement between the research and clinical diagnoses (p = 0.003) and indicates that clinicians choose the less severe diagnosis for psychotic patients. We conclude that a more stringent criterion C for the schizoaffective disorder diagnosis will address an implicit bias in clinical practice and will affect the prevalence of the psychotic disorder diagnoses.

The gender gap in stroke: a meta-analysis

Several studies have indicated that gender differences might exist in stroke. Our goal was to perform a comprehensive meta-analysis in order to evaluate and quantify stroke gender disparities through a systematic search of relevant articles published up to October 2009 and addressing gender related differences in ischemic stroke risk factors, stroke subtype and severity, diagnostic tests, and acute phase and secondary prevention treatments. Forty-five articles were included in the analysis, representing a total of 673,935 patients. Women were globally older than men (+5.2 years) and suffered more hypertension (P = 0.017) and atrial fibrillation (P < 0.001), although they were less likely to drink alcohol (P < 0.001), smoke cigarettes (P < 0.001), present hyperlipidemia (P = 0.033) or diabetes (P = 0.003) than men. Baseline stroke severity was not different between genders. Women suffered more cardioembolic strokes, while men had more atherothrombotic strokes. Moreover, women were less likely to receive stroke-related treatments, such as antiplatelets (P < 0.001), statins (P < 0.001), and tPA (P < 0.001) than men. Although meta-regression did not identify age or stroke etiology as sources of heterogeneity, caution should be taken as that analysis was possible only for gender differences in secondary prevention with antiplatelets because of limited data for other end points. Gender differences have been identified on the risk factors profile and diagnostic and therapeutic management of patients with ischemic stroke. Active measures should thus be taken to avoid bias in clinical practice.

Is it possible to identify patient's sex when reading blinded illness narratives? An experimental study about gender bias

BackgroundIn many diseases men and women, for no apparent medical reason, are not offered the same investigations and treatment in health care. This may be due to staff's stereotypical preconceptions about men and women, i.e., gender bias. In the clinical situation it is difficult to know whether gender differences in management reflect physicians' gender bias or male and female patients' different needs or different ways of expressing their needs. To shed some light on these possibilities this study investigated to what extent it was possible to identify patients' sex when reading their blinded illness narratives, i.e., do male and female patients express themselves differently enough to be recognised as men and women without being categorised on beforehand?MethodsEighty-one authentic letters about being diseased by cancer were blinded regarding sex and read by 130 students of medicine and psychology. For each letter the participants were asked to give the author's sex and to explain their choice. The success rates were analysed statistically. To illuminate the participants' reasoning the explanations of four letters were analysed qualitatively.ResultsThe patient's sex was correctly identified in 62% of the cases, with significantly higher rates in male narratives. There were no differences between male and female participants. In the qualitative analysis the choice of a male writer was explained by: a short letter; formal language; a focus on facts and a lack of emotions. In contrast the reasons for the choice of a woman were: a long letter; vivid language; mention of emotions and interpersonal relationships. Furthermore, the same expressions were interpreted differently depending on whether the participant believed the writer to be male or female.ConclusionIt was possible to detect gender differences in the blinded illness narratives. The students' explanations for their choice of sex agreed with common gender stereotypes implying that such stereotypes correspond, at least on a group level, to differences in male and female patients' illness descriptions. However, it was also obvious that preconceptions about gender obstructed and biased the interpretations, a finding with implications for the understanding of gender bias in clinical practice.

End‐digit preference in general practice: A comparison of the conventional auscultatory and electronic oscillometric methods

Introduction. In clinical practice, end‐digit preference is a common feature of blood pressure (BP) measurements. A wider use of electronic BP measuring machines could decrease this observer‐linked artefact. The purpose of this analysis was to investigate the frequency of end‐digit preference and to evaluate the impact of this observer bias on the assessment of the BP control induced in a large group of hypertensive patients treated with a calcium‐channel blocker in whom BP was measured either with an automatic device or with a conventional sphygmomanometer. Methods. Five hundred and four physicians participated in the study and 2199 patients were included. Treatment with lercanidipine was introduced at a dosage of 10 mg and titration to 20 mg was optional according to the physician's decision. BP was assessed at 4 and 8 weeks. To measure BP, physicians could use either a standard mercury sphygmomanometer or a pre‐defined validated semi‐automatic device (Microlife Average Mode, BP 3AC1‐1, Microlife Corporation, Berneck, Switzerland) but they had to use the same method throughout the study. Physicians had to transcribe all BP measurements onto case report forms. Results. Very marked digit preferences were observed for both the conventional and the automatic measurements, being most prominent for the digit “0” (52% and 25%, respectively) followed by a preference for the digit “5” (19% and 15%). The use of the semi‐automatic device reduces to a certain extent the frequency of the bias but the problem remains if physicians have to transfer the BP values onto case report forms. The end‐digit preference has a major impact on the evaluation of a treatment effect and on the assessment of the percentage of patients achieving target BP in a population. Conclusion. These results confirm that end‐digit preference remains a serious bias in clinical practice. This bias has important consequences when evaluating the efficacy of a new antihypertensive drug. There is a need for training programmes and quality controls in clinical practice. The development of automatic systems with a direct transfer of BP values from the measuring device to the clinical chart or to the case report form should be encouraged.

Difficult Decisions in the Intensive Care Unit: An Illustrative Case

Difficult clinical decision-making is a common experience in intensive care units. There is often considerable pressure on time and decisions may have to be made in a stressful environment. Patients in the intensive care unit not infrequently present with extreme or rare manifestations of a disease process. Clinical evidence to guide management of such patients may be incomplete, non-existent, or its relevance to the problem at hand may be questionable. In this context, formal decision-making analytical tools are often impractical. Unconscious cognitive biases have been shown to play an important role in medical decision-making, particularly in these settings. While mostly these contribute to doctors making appropriate and timely decisions, occasionally they lead to errors. Despite 30 years of research into models of clinical reasoning, most doctors are unaware of how biases affect their thinking and are unfamiliar with techniques of detecting and neutralising bias in clinical practice. We present the case of a patient with Wegener's granulomatosis, which highlights many of the difficulties outlined above. We review the clinical evidence for our decisions at each stage and explain the rationale for our choices, highlighting the many situations for which high quality evidence was lacking. Examples of cognitive bias are identified and techniques of metacognition (thinking about thinking) that can be useful in limiting the effects of bias on complex decision-making are reviewed. The intensivist's evaluation of management alternatives has an important role in steering medical management towards optimal patient outcomes.