Diversion and Deviation: How Distracting Contextual Factors Amplify Cognitive Biases in Clinical Reasoning

Rationale: Mistakes in clinical reasoning are common. Cognitive biases have gained attention as potential sources of error. Over 100 biases have been defined, and over 40 have been identified in clinical reasoning literature. Understanding contextual factors (e.g., clinical setting or emotions) that influence clinical reasoning is a first step towards improving reasoning and reducing errors. Aims and Objectives: Explore the interactions of cognitive biases and distracting contextual factors and their influence on clinical reasoning accuracy. Methods: The authors conducted a simulation study. Participants watched video encounters of common conditions with or without added distracting contextual factors (DCFs, e.g., English as a second language or patient anxiety), then completed a post-encounter form and a think-aloud exercise. Reasoning was analyzed with an analytic integrative approach of latent thematic analysis. MANOVA assessed for potential associations of biases and contextual factors on reasoning accuracy, which was followed with univariate ANOVA. Results: Thirteen cognitive biases were identified. Anchoring, availability, and confirmation bias were most common. MANOVA found lower diagnostic reasoning accuracy in cases with DCFs (72% vs. 80%). There was a lower but not statistically significant difference in management reasoning accuracy (70% vs. 73%). Univariate ANOVA found that the number of biases and the cooccurrence of bias and a DCF was associated with lower diagnostic reasoning accuracy. Three themes emerged when exploring biases' influence on reasoning: (1) gestalt from context or error avoidance, (2) optimistic processing, and (3) momentum clouds reasoning in the present and afterward. Two additional themes emerged when exploring the interactions between biases and DCFs: (1) lack of confidence and knowledge deficit, and (2) emphasizing easily available information. Conclusions: Cognitive biases can affect clinical reasoning in multiple ways. DCFs may amplify the negative influence of biases on diagnostic reasoning accuracy. Exploring the interactions of cognitive biases, DCFs, and clinical reasoning, as well as delineating diagnostic reasoning from management reasoning may help future research and interventions improve reasoning accuracy.