Cognitive debiasing 2: impediments to and strategies for change

Abstract

In a companion paper, we proposed that cognitive debiasing is a skill essential in developing sound clinical reasoning to mitigate the incidence of diagnostic failure. We reviewed the origins of cognitive biases and some proposed mechanisms for how debiasing processes might work. In this paper, we first outline a general schema of how cognitive change occurs and the constraints that may apply. We review a variety of individual factors, many of them biases themselves, which may be impediments to change. We then examine the major strategies that have been developed in the social sciences and in medicine to achieve cognitive and affective debiasing, including the important concept of forcing functions. The abundance and rich variety of approaches that exist in the literature and in individual clinical domains illustrate the difficulties inherent in achieving cognitive change, and also the need for such interventions. Ongoing cognitive debiasing is arguably the most important feature of the critical thinker and the well-calibrated mind. We outline three groups of suggested interventions going forward: educational strategies, workplace strategies and forcing functions. We stress the importance of ambient and contextual influences on the quality of individual decision making and the need to address factors known to impair calibration of the decision maker. We also emphasise the importance of introducing these concepts and corollary development of training in critical thinking in the undergraduate level in medical education.

Critical Thinking Education and Debiasing (AILACT Essay Prize Winner 2013)

“…The particular granularity of our formulations strike us as more felicitous, however, and the employment of levels is a key refinement. For example, Croskerry et al (2013b) place the strategy of "training on theories of reasoning and medical decision making" on a par with creating "supportive environments" for sound reasoning (pp. ii67-ii68).…”

“…The difficulty of teaching debiasing skills that could be deployed in a strictly atomistic or individualistic way counts in favor of teaching and investing also in more collective debiasing strategies and infrastructure that would serve the latter sorts of interests. This approach will encompass teaching not just individual skills and knowledge, but skills that enable the 1 In fact the distinctions between approaches to critical thinking that we propose in the following remarks should be helpful in characterizing the kinds of clinical training strategies described by Croskerry et al (2013aCroskerry et al ( , 2013b. 2 Below, we identify some methods that would fall under IA that we believe to be relatively promising.…”

“…It is also central to some reviews on the topic (e.g., Larrick 2004), while its influence can be seen also in training contexts beyond that of a critical thinking course. An example of this latter type of context is Croskerry, Singhal, & Mamede's (2013a, 2013b approach to cognitive debiasing for clinicians' medical judgments: even though Croskerry et al record a "general pessimism […] about the feasibility of cognitive debiasing" (Croskerry et al 2013a, p. ii63), they adopt the recommendation that clinicians "must be informed and recognise the need for constant vigilance and surveillance of their [own] thinking to mitigate diagnostic and other clinical errors" (Croskerry et al 2013b, p. 6). 1 It is noteworthy that IA characterizes much of how critical thinking education treats debiasing, we contend, because when one considers the empirical evidence bearing on it, the most plausible simple view of IA is that it is-at least in most casesfalse.…”

The bias of the question posed: a diagnostic “invisible gorilla”

“…A large number of cognitive biases have been noted to lead to diagnostic errors in medical practice [2]. Self-reflection on potential biases (so-called "debiasing") is advocated as part of the diagnostic process, in order to identify and compensate for biases before they lead to diagnostic errors [2,[4][5][6]. Familiarity with common, clinically-relevant biases is therefore a necessary step in avoiding them.…”

Diagnostic error, overconfidence and self-knowledge

“…A natural suggestion is that if (OH) is correct then one way to reduce levels of diagnostic error would be to make physicians aware of the full extent of their tendencies to err and the role of overconfidence in causing diagnostic error. In effect, the proposal is that overconfidence and diagnostic errors due to overconfidence can be addressed by increasing physician self-knowledge or self-awareness (BorrellCarió and Epstein, 2004;Croskerry et al, 2013b).…”