Letters to the Editor
In Reply to Kunimatsu and Yoshizawa: We and our coauthors thank you, Drs. Kunimatsu and Yoshizawa, for providing another excellent example of how clinical reasoning can be swayed by cognitive bias. The clinical case you describe illustrates availability bias. We agree that contextual factors may have impaired your initial differential diagnosis because, certainly, you and your colleagues were affected by the tragedy as well. Diagnostic error is a common and important cause of poor patient outcomes, and understanding that contextual factors can heavily influence our diagnostic reasoning is essential. These situations are ubiquitous.
Your example further highlights the importance of incorporating formal training in clinical reasoning into physician training. At our institution, in our differential diagnosis course for medical students, we introduce the concept of cognitive bias and emphasize at least three diagnoses and two organ systems for the initial evaluation of a patient’s primary problem. We also have incorporated the topics of cognitive bias and diagnostic error into the curriculum for internal medicine residents. Our hopes are that when young physicians experience cognitive bias, they will be able to recognize it and learn from their experience.
Your eventual broader differential diagnosis led you to the appropriate diagnosis and care. Learning how to identify and mitigate cognitive bias (e.g., by always entertaining a broader differential diagnosis) is critical to providing outstanding patient care.
Alexis Ogdie, MD, MSCE
Instructor of medicine, Division of Rheumatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; alexis. firstname.lastname@example.org.
Jennifer Myers, MD
Associate professor of medicine, Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
Joan Von Feldt, MD, MSEd
Professor of medicine, Division of Rheumatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.