Cognitive Debiasing Strategies for the Emergency Department

The emergency department (ED) is a high-risk environment where diagnostic error is not uncommon. Most errors (70%) are due to faulty reasoning.1 Decision making occurs through two primary pathways: 1) Pattern recognition is fast, intuitive, and heuristically driven and occurs largely unconsciously; 2) analytic thinking is slow and deliberate and takes place under conscious control. When functioning optimally, expert clinicians toggle back and forth between these two systems depending on the complexity of the case and the demands of the environment. Systematic errors (known as biases) can interfere with reasoning via either pathway, but predominately affect the abbreviated decision making associated with pattern recognition. Thus, a critical feature of cognitive bias mitigation involves deliberate “switching” from intuitive to analytical processing and the deliberate use of debiasing strategies.2, 3 Prominent cognitive psychologist Daniel Kahneman (Thinking Fast and Thinking Slow) holds the largely pessimistic view that physicians are incapable of employing bias mitigation strategies to overcome their flawed intuition.4 Recent research, however, offers strong converging evidence that doctors do have the means to overcome bias through education.5 This Med Ed download focuses on some of the most common biases amongst ED providers so that you can more effectively recognize and mitigate bias in yourself and in your learners. The aim is to help teachers and learners develop a common language around bias to make you STOP, THINK about the thinking that underlies these errors, and ACT by proposing debiasing strategies to address them. See the patient yourself and form your own impressions before reading the triage summary or nurses' notes or hearing a learner's case presentation. Two heads (or many) are better than one. You will invariably each pick up important data that the other person did not. Collectively this information forms a more complete picture of the case. “Group think” should be used for difficult cases. Ask a colleague for an independent assessment or a second opinion. Do not “frame” the patient to a colleague; give objective data.