Effect of Availability Bias and Reflective Reasoning on Diagnostic Accuracy Among Internal Medicine Residents
Effect of Availability Bias and Reflective Reasoning on Diagnostic Accuracy Among Internal Medicine Residents
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DOI：
10.1001/jama.2010.1276
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发表时间：
2010-09-15
影响因子：
120.7
通讯作者：
Schmidt, Henk G.
中科院分区：
文献类型：
--
作者：
Mamede, Silvia;van Gog, Tamara;Schmidt, Henk G.
背景诊断错误与临床推理中的偏见有关。缺乏关于偏见的认知机制和教育策略的有效性的实证证据来抵消它们。目的探讨最近的临床问题经验是否会引起可用性偏见（根据想到的容易程度高估诊断的可能性）导致诊断错误，实验研究于2009年在鹿特丹的伊拉斯谟医学中心进行，有18名第一年和18名第二年的内科住院医师。参与者首先评估了6例临床病例（1期）的诊断。随后，他们通过非分析性推理诊断了8例不同的病例，其中4例的发现与先前评估的病例相似，但诊断不同（第2阶段）。这4例患者随后通过反思推理再次诊断（第3阶段）。主要结果测量平均诊断准确性评分（满分，4.0）通过非分析性（第2阶段）或反思性（第3阶段）推理解决了或没有以前暴露于类似问题的案例，并且可能存在偏见的频率结果无主效应，但“培训年限”与“近期有类似问题的经历”之间存在显著的交互效应。第二年住院医师的结果与可用性偏倚一致，他们在与以前遇到的病例相似的病例中得分较低（1.55; 95%置信区间[CI]，1.15-1.96），而在其他病例中得分较低（2.19; 95% CI，1.73-2.66; P= 0.03）。在第一年住院医师中未观察到这种模式（2.03; 95%CI，1.55-2.51 vs 1.42; 95%CI，0.92-1.92; P= 0.046）。第二年住院医生提供的第一阶段诊断更频繁地为2期病例，他们以前遇到的比那些他们没有（平均频率每居民，1.44; 95% CI，0.93-1.96 vs 0.72; 95% CI，0.28-1.17; P= 0.04）。推理模式的主效应显著：反思对第二年住院医师的相似病例的诊断效果优于非分析推理（2.03; 95% CI，1.49-2.57）和第一年住院医师（2.31; 95%CI，1.89-2.73; P=.006）。结论当面对与以往相似的病例，使用非分析推理时，第二年住院医师的错误与可用性偏差一致。随后应用诊断反射倾向于对抗这种偏见，它提高了第一年和第二年居民的诊断准确性。美国医学会杂志2010;304（11）：1198-1203 www.jama.com
Context Diagnostic errors have been associated with bias in clinical reasoning. Empirical evidence on the cognitive mechanisms underlying biases and effectiveness of educational strategies to counteract them is lacking.Objectives To investigate whether recent experience with clinical problems provokes availability bias (overestimation of the likelihood of a diagnosis based on the ease with which it comes to mind) resulting in diagnostic errors and whether reflection (structured reanalysis of the case findings) counteracts this bias.Design, Setting, and Participants Experimental study conducted in 2009 at the Erasmus Medical Centre, Rotterdam, with 18 first-year and 18 second-year internal medicine residents. Participants first evaluated diagnoses of 6 clinical cases (phase 1). Subsequently, they diagnosed 8 different cases through nonanalytical reasoning, 4 of which had findings similar to previously evaluated cases but different diagnoses (phase 2). These 4 cases were subsequently diagnosed again through reflective reasoning (phase 3).Main Outcome Measures Mean diagnostic accuracy scores (perfect score, 4.0) on cases solved with or without previous exposure to similar problems through nonanalytical (phase 2) or reflective (phase 3) reasoning and frequency that a potentially biased (ie, phase 1) diagnosis was given.Results There were no main effects, but there was a significant interaction effect between "years of training" and "recent experiences with similar problems." Results consistent with an availability bias occurred for the second-year residents, who scored lower on the cases similar to those previously encountered (1.55; 95% confidence interval [CI], 1.15-1.96) than on the other cases (2.19; 95% CI, 1.73-2.66; P=.03). This pattern was not seen among the first-year residents (2.03; 95% CI, 1.55-2.51 vs 1.42; 95% CI, 0.92-1.92; P=.046). Second-year residents provided the phase 1 diagnosis more frequently for phase 2 cases they had previously encountered than for those they had not (mean frequency per resident, 1.44; 95% CI, 0.93-1.96 vs 0.72; 95% CI, 0.28-1.17; P=.04). A significant main effect of reasoning mode was found: reflection improved the diagnoses of the similar cases compared with nonanalytical reasoning for the second-year residents (2.03; 95% CI, 1.49-2.57) and the first-year residents (2.31; 95% CI, 1.89-2.73; P=.006).Conclusion When faced with cases similar to previous ones and using nonanalytic reasoning, second-year residents made errors consistent with the availability bias. Subsequent application of diagnostic reflection tended to counter this bias; it improved diagnostic accuracy in both first-and second-year residents. JAMA. 2010;304(11):1198-1203 www.jama.com