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What is Your Blindspot: Managing Cognitive Bias

Taryn R Taylor MD, MEd

I can vividly remember my first day as a REAL doctor. I started on the pediatric pulmonology service, and recall spending what felt like an hour, deliberating whether I could order Tylenol for my patient. Would it interact with the Pulmozyme treatment? Fortunately, I had very patient senior resident who calmed my nerves and was empathetic to my intern anxiety.  July is an exciting, terrifying, rewarding and sometimes frustrating month, as we celebrate a new “medical year.” Whether or not you subscribe to the controversial premise of the July effect, there is no doubt that during this time you can leave a pivotal educational footprint in the life and career of a young doctor.

As we lead these learners on this educational journey, one of the most poignant lessons we can teach them is how to think critically. This includes recognizing and managing cognitive biases. Pattern recognition, which primarily occurs unconsciously, and analytical thinking which is deliberate and conscious, are the principle means by which we make medical decisions.  Cognitive biases are errors in reasoning that affect primarily the pattern recognition pathway. Debiasing strategies focus on transitioning from pattern recognition to a more analytic approach.1  By utilizing these debiasing strategies, we can reduce clinical errors committed by our learners and ourselves.

The first step in this process is to define and recognize the different type of cognitive errors that most commonly occur in medicine.

Anchoring: The patient’s chief complaint is sore throat, and they report an exposure to a family member with “strep.” This preliminary information seems quite convincing for a Group A beta-hemolytic streptococcal infection. However, upon further history gathering, the patient reveals symptoms of periodic heartburn, frequent belching and the sensation of food “getting stuck.”  Your learner, however, despite this additional information, is convinced that the patient should be treated immediately with antibiotics for the infectious process. This is an example of anchoring, during which one prematurely locks on to a diagnosis based on important preliminary information and fails to adjust this impression when additional information becomes available.

Information Bias: Innovative medical technology has afforded us the use of advanced radiologic imaging techniques and near instantaneous laboratory testing results. The utilization of such is not always efficient, affordable or practical. The tendency to believe that the more data one can collect to support a diagnosis the better, is called information bias.

Blind Spot Bias: As a seasoned, skilled physician, you have developed well defined illness scripts. You can recognize when a learner is going astray and are able to gently guide him or her back on track. Perhaps you do not recognize your own tendency towards gender bias or stereotyping. This is an example of blind spot bias: the ability to recognize the weakness or cognitive errors in others, and a tendency to overlook our own.

Over 100 different types of cognitive biases have been described in the literature. We are all vulnerable to these types of errors and being aware of them is a meaningful start to mitigating their effects. Wilson and Brekke 2 suggest an algorithmic approach to managing bias:

  • Become aware of the bias
  • Ensure that you and your learner are motivated to correct the bias
  • Recognize the magnitude of the bias
  • Apply an appropriate debiasing strategy

The authors suggest that successful completion of these steps lead to optimal decision making, however failure to complete these tasks leads to distortion of clinical reasoning. Dr. Croskerry 3,4 describes the following debiasing strategies.

  • Consider the alternatives: Routinely ask, “What else might this be?” Systematically generate and work through a differential diagnosis.
  • Metacognition: Metacognition is defined as the awareness and understanding of one’s own thought processes. Encourage learners to reflect on their approach to problem solving and self-critique, asking themselves what cognitive biases are at risk.
  • Decrease reliance on memory: One can improve the accuracy of judgments by using cognitive aids. These include mnemonics, clinical practice guidelines and algorithms, and the use of FOAM (Free Open Access to Meducation)
  • Feedback: Provide specific and timely feedback to decision makers so that errors are immediately appreciated, understood, and corrected.
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    Help support the thousands of children affected by Hurricane Harvey

    The EMS for Children Innovation & Improvement Center recently reached out to the Texas Pediatric Society Foundation (TPSF) to request that they set up an Emergency Relief/Recovery giving category targeting the special needs of children post disaster. The mission of the TPSF is to enhance the well-being of Texas children by supporting efforts to help improve their health, safety and education and to make a positive impact on their lives and futures.

    The funds collected by the TPSF for Emergency Relief/Recovery will be provided in the form of grants to emergency relief and recovery efforts conducted by physicians, community advocates and other child advocacy organizations in Texas during times of a natural disaster such as a hurricane, flood, fire, earthquake and other emergency events. To find out more about the TPSF visit their website at https://txpeds.org/tps-foundation. To make a donation to the TPSF Emergency Relief/Recovery giving category use the online form.

    The Emergency Medical Services for Children Innovation and Improvement Center (EIIC), in collaboration with its national partners and experts across the EMS continuum, recognizes the needs of children post disaster that can be supported through programs that target: mental health for the child experiencing a disaster; exposure to flood waters, industrial site contaminants, molds and their associated illnesses; dealing with health issues for those housed in close proximity in shelters; and others.

    Donate now!

    Donate today to help strengthen the Texas emergency medical services continuum of care for children.

    Pediatric Section Meeting and Reception in Las Vegas TONIGHT!!!

    You’re invited to the Pediatric Section Meeting and Reception at the Advanced Pediatric Emergency Medicine Assembly.  Come join the party and mingle with other top minds in pediatric emergency medicine.

    Pediatric EM Section Meeting and Reception
    Wednesday, April 26, 2017
    5:30 – 7:00 pm
    Versailles Ballrooms 3 and 4
    Paris Hotel, Las Vegas

    We look forward to seeing you there!

    Peanuts and Choking

    Dr. Tamara Willoughby

    Recently, the lay press reported a promising breakthrough in decreasing the frequency of peanut allergies in children at high risk for peanut allergy by early introduction of peanuts. (1)  In the study “peanuts” were introduced to infants between the ages of 4 and 11 months. (1)  The research shows promise to combat the increasing prevalence of peanut allergy in Western countries. (1) Although, not discussed in news reports, the peanut product given to infants in the study was not whole peanuts.  Infants were given “Bamba,” a peanut butter flavored puffed maize product. (1) Some news reports, although not all, discussed that early introduction of peanuts should be done under a physician’s care. The general public should also be reminded about the choking risk of peanuts especially in children 3 and under and that babies in this study were not given whole peanuts.   Choking is a leading cause of mortality and morbidity in children 3 and under with food, toys and coins most often the culprits. (2) Small children are vulnerable to choking in many ways.  A child’s airway occludes easily with small objects because of the small diameter of the airway and young children often can’t cough with enough force to dislodge a foreign body. (2) Additionally until molars erupt, children are unable to sufficiently chew food into smaller portions adequate for swallowing. (2) Finally, even though children at age 3 to 4 have molars, they are still learning to chew and are easily distracted which can lead to choking. (2) Approximately 1 child every 5 days in the United States dies from choking on food. (2) High risk foods for choking include hot dogs, hard candy, peanuts, nuts and seeds, whole grapes, raw carrots, apples,  popcorn, marshmallows, chewing gum and globs of peanut butter. (2)  In conclusion,  lets take this opportunity to educate the public regarding choking risks in children along with enthusiasm for promising  research on peanut allergy prevention.

    1. Du Toit, et al, Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy. NEJM, 2015: 372(9):803-812.
    2. Committee on Injury Violence and Poison Prevention, Prevention of Choking Among Children. Pediatrics, 2010:125(3):601-7.