There are some remedies to avoid framing bias:
• Acknowledge that framing bias may exist, and be on the lookout for it.
• Improve your knowledge and experience through use of simulations, improved feedback on decision outcomes, and focused CME on known pitfalls in specific diseases/scenarios.
• Improve your clinical reasoning through reflective practices. Slow down (easy for me to say) and think. Perform a metacognitive review, and recognize the traps associated with relying on rules-of-thumb.
• Provide cognitive help through technological support and algorithms (eg, through electronic medical record prompts), and ensure access to second opinions from colleagues.
• Reduce the “cognitive load” by modifying work schedules and the number of patients to be seen. Reduce distractions and interruptions in the work environment.6
With the time constraints and frenzied nature of modern health care, there is, I believe, value in stopping to reflect on our thinking, particularly when an original presumption about a diagnosis appears not to succeed in explaining the complaint or empiric therapy does not improve the patient’s symptoms. At these times, drawing on both intuitive and deliberative thinking can be fundamental in avoiding thought traps and moving us onto a better diagnostic path.
I have not meant to oversimplify an obviously complex topic, but I would love to hear from you on your opinion about this topic. Contact me at PAEditor@frontlinemedcom.com.
REFERENCES
1. Nkanginieme KEO. Clinical diagnosis as
a dynamic cognitive process: application
of Bloom’s taxonomy for educational objectives in the cognitive domain. Med Educ Online [serial online]. 1997;2:1. www.msu.edu/~dsolomon/f0000007.pdf. Accessed May 14, 2014.
2. Phua DH, Tan NC. Cognitive aspect of diagnostic errors. Ann Acad Med Singapore. 2013; 42(1):33-41.
3. Charlin B, Tardif J, Boshuizen HP. Scripts and medical diagnostic knowledge: theory and applications for clinical reasoning instruction and research. Acad Med. 2000;75(2):182-190.
4. Graber ML, Franklin N, Gordoin R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-1499.
5. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-780.
6. Perkocha L. Cognitive error in medical diagnosis: what we now know. Presented at University of Hawaii John A Burns School of Medicine Reunion, July 27, 2013. https://jabsom.hawaii.edu/JABSOM/departments/CME/doc/Perkocha.pdf. Accessed May 14, 2014. 5, 2014.