Evidence of sequence-related bias in clinical performance evaluation among healthcare professionals

Cognitive biases are a known source of diagnostic error in healthcare, but their influence on rehabilitation assessments remains understudied. This study examined sequence bias—a novel form of contextual bias in which prior exposure to high or low performance affects clinicians’ evaluations of subsequent moderate performances. We aimed to determine whether this bias affects clinicians’ scoring of lateral pinch modulation tasks and whether it is associated with clinicians’ cognitive style and confidence levels. Thirty licensed physical and occupational therapists assessed lateral pinch modulation performances using a Visual Analogue Scale, following exposure to blocks of either high- or low-quality performances. Confidence ratings were recorded after each assessment. Participants also completed the Rational-Experiential Inventory (REI-40) to assess cognitive style. Clinicians consistently underestimated moderate performances following both high- and low-quality performance blocks, with a stronger bias after exposure to high-quality performances ( p <.001, r = .658). Linear mixed-effects modelling revealed a significant main effect of experiential engagement (REI-D) on evaluation bias ( p =.001), as well as a significant interaction between REI-D and contextual condition ( p =.0496), indicating that the association was stronger following high-quality performance blocks than following low-quality performance blocks. Higher experiential ability (REI-C; p =.006) and experiential engagement (REI-D; p =.021) were associated with lower confidence ratings. In addition, significant interactions between contextual condition and rational ability (REI-A; p =.001) and rational engagement (REI-B; p =.040) indicated that the relationship between rational thinking style and confidence differed according to the contextual condition. Sequence bias significantly influences clinicians’ performance evaluations, and was more pronounced among clinicians with higher self-reported experiential engagement. The association between rational cognitive style and confidence differed between the high- and low-quality performance contexts. These findings highlight the potential influence of contextual biases in rehabilitation assessment and support the need for further research to determine their impact in real-world clinical settings.