Bias, Medical Errors, and How to Decide Better

In 2021 in Austria, an 82-year-old man went in for a left leg amputation and came out with the wrong leg removed.

That same year, a Cleveland-based University Hospitals reported that surgeons transplanted a kidney to a patient when it was planned for another.

The examples above are alarming. They may represent extreme situations, but harmful medical errors are not uncommon. It is estimated that as many as a quarter-million deaths occur each year because of medical error (Markary, 2016). As many as three-quarters of errors are made from a faulty synthesis of information from cognitive bias.

Strategies that improve decision-making and reduce errors are essential in the fast-changing landscape of healthcare. Systems can be developed to check and remind doctors. Doctors can receive training in methods to ask important questions and reduce bias.

Decision-making skills can start even while students are in medical school. Workshops that impart cognitive debiasing practices can equip students with ways to make better decisions and “smarter” errors. Much of medicine relies on human interaction or how a doctor’s training relates to a patient’s concerns.

This article will outline some theories of decision-making and consciousness. It will provide examples of how thinking about our thinking can offer a strategy to reduce bias and decide better.

Theories of Decision-Making

Psychologists have developed theories of behavior, like decision-making. They are models to understand the components of these actions.

One of these describes decision-making as a dual-system: either a decision is rapid, intuitive, and unconscious (system 1), or it is slow, intentional, and conscious (system 2) (Kahneman, 2011). We make most of our decisions in system 1 mode, because they require less energy for the brain. They are also more prone to bias.

Recently, De Houwer proposed a way to look at behaviors through the lens of relational knowledge, that is, how we relate to the environment (De Houwer, 2019):

The brain responds to cues from the environment, whether we decide in a reflexive, conditioned way or rely on the knowledge and have significant ramifications. Our brains draw from experience and innate reflexes to dynamically decide on a current circumstance in both situations. The accuracy in our assessment relies on fine-tuning our consciousness.

Consciousness and How We Interact

Awareness allows a catcher to judge a pop-up fly ball and catch it with their mitt. In the same manner, a doctor assists a patient in discovering what ails them through active listening and the use of a stethoscope or other instruments.

A detailed discussion of consciousness is outside the scope of this article. Briefly, consciousness occurs from the brain’s coordinated actions of anticipating, receiving, and processing input and then deciding its relevance (Vithoulkas, 2014; Kotchoubey, 2018). The brain gains awareness of the environment through the senses, cognition, imagination, emotion, and memory. Learning develops these processes and plays a crucial role in improving understanding.

Consciousness is a behavior that the “brain learns to do” (Cleeremans, 2020). It relates to the environment to assess and decide. Three key factors build the experience of consciousness: playcommunication, and the use of tools (Kotchoubey, 2018). In the following paragraphs, I’ll define the elements in the context of medicine.

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Play

Play provides a learner with an initial period to determine how actions affect others and the environment. Although it is relatable to something more serious, play is generally safe, social, and enjoyable. There are many different types, including role or imaginary, games with rules, physical, and social. In many ways, medical school training is akin to play. The interaction happens by way of learning through doing.

Communication

Communication requires a more complicated process as people seek to understand each other. The brain receives sound frequencies as inputs to the cochlea of the inner ear, translating them into words and then cross-referencing the words with stored memories. The dialogue between doctor and patient is dynamic, as the doctor calibrates reality through question and answer. However, as spoken words cross the rift between two people, the bridge they traverse is fragile. Even though each word has an objective meaning in a dictionary, every person attaches a unique significance.

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Tools

A tool is a form of applied knowledge that extends the brain’s range of interaction. It can be a simple apparatus, such as a stethoscope, reflex hammer, or otoscope, which amplify the senses, or technological advancements that enhance our understanding of reality. In medicine, doctors use technology to give them greater precision in finding the cause and location of a disease and administering therapy.

An important point regarding consciousness is that the brain constantly tests hypotheses in preparation for environmental changes (Kotchoubey, 2018). It predicts and corrects conclusions as the outside reveals more information. It projects a best-fit picture of the world through our understanding of things. On the one hand, we can fill in the gaps like missing pieces in a jigsaw puzzle. The brain does this by filtering and decoding the input received from the senses. It applies knowledge and experience to predict reality.

Bias

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Our brains receive input as it is revealed in the present to make a decision using past knowledge. Most decisions in an average human are quick, pattern-related judgments – probably about 95% of the time (system 1 perspectives). Sometimes these short-hand rules can be honed and become fairly dependable (heuristics).

However, the reality that is perceived is not the complete story. It is prone to bias and inaccuracy. This is what is meant by cognitive bias.

Bias is a natural cognitive pathway that leads to errors in thought. It is a behavior. There are more than thirty types of biases. They result from faulty assumptions on the generalizability of past experiences, future predictions, and limited data to make conclusions.

The incorrect synthesis of information through cognitive bias is the cause of more than three-quarters of medical errors. Here is an article on bias from Your Health Forum. Consequently, it is crucial for students, residents, and physicians to decide better or make more thoughtful mistakes.

Metacognition

Metacognition is a self-assessment process involving “thinking about thinking.” It affords an excellent strategy to become aware and reduce cognitive bias (Colbert et al., 2015). Metacognitive awareness requires two components: 1) knowledge of cognition and 2) awareness of cognition.

Beginning with self-reflection on a thought process, a person determines if it is system 1 or system 2 thinking. Next, they consider the impact of cognitive distortion on the conclusions. The person then enacts strategies to reapproach their thoughts.

Some examples of strategies include behavior to slow decision-making, such as reviewing the indications, dose, and frequency of medication before and after ordering it. Another way to ensure that bias is less influential is to ask questions, such as “Why do I think this is X condition?” or “Are there other possibilities?” A third way is through group interaction. In one study, physicians were more accurate as a group, even as little as two, coming up with a diagnosis when discussing the case with colleagues. Feedback is also an essential tool in medical training to make better decisions.

Ultimately, it teaches individuals to make lasting changes in their behaviors. As an added benefit, practicing metacognition affords a physician empathic listening skills, as they consider alternative angles.

Metacognition

Awareness of one’s own knowledge – what one does and

doesn’t know – and one’s ability to understand, control, and

manipulate one’s cognitive process.

Meichenbaum, 1985

Bibliography

Cleeremans, et al. Learning to be Conscious.

Colbert, et al. Teaching Metacognitive Skills: Helping Your Physician Trainees in the Quest to “Know What They Don’t Know.” Am Journ of Med. 2014; 128(3). doi: 101016/j.amjmed.2014.11.001.

De Houwer J. Moving Beyond System 1 and System 2. Conditioning, Implicit Evaluation, and Habitual Responding Might Be Mediated by Relational Knowledge. Exp Psychol. 2019; 66(4): 257-265.

Kotchoubey B. Human Consciousness: Where is it from and what is it for. Front Psychol. 2018; 9:567. doi: 10.3389/fpsyg.2018.00567.

Makary M, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016; 353:i2139. doi: 10.1136/bmj.i2139.

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