Effect of Availability Bias and Reflective Reasoning on Diagnostic Accuracy Among Internal Medicine Resident

Silvia Mamede Studart Soares, Tamara van Gog, K van den Berge, Remy Rikers, Jan Saase, C van Guldener, Henk Schmidt

Research output: Contribution to journalArticleAcademicpeer-review

232 Citations (Scopus)


Context. Diagnostic errors have been associated with bias in clinical reasoning. Em- pirical 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 pro- vokes 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 reflec- tion (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 medi- cine residents. Participants first evaluated diagnoses of 6 clinical cases (phase 1). Subse- quently, 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 nonana- lytical (phase 2) or reflective (phase 3) reasoning and frequency that a potentially bi- ased (ie, phase 1) diagnosis was given. Results. There were no main effects, but there was a significant interaction effect be- tween ¿years of training¿ and ¿recent experiences with similar problems.¿ Results con- sistent 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. Sub- sequent application of diagnostic reflection tended to counter this bias; it improved diagnostic accuracy in both first- and second-year residents.
Original languageEnglish
Pages (from-to)1198-1203
Number of pages6
JournalJAMA - Journal of the American Medical Association
Issue number11
Publication statusPublished - 2010


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