• Sílvia Mamede, Marco Goeijenbier, SchuitStephanie C ESCEDepartment of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands., Marco Antonio de Carvalho Filho, Justine Staal, Laura Zwaan, and Henk G Schmidt.
• Institute of Medical Education Research Rotterdam, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands. s.mamede@erasmusmc.nl.
• J Gen Intern Med. 2021 Mar 1; 36 (3): 640-646.

BackgroundBias in reasoning rather than knowledge gaps has been identified as the origin of most diagnostic errors. However, the role of knowledge in counteracting bias is unclear.ObjectiveTo examine whether knowledge of discriminating features (findings that discriminate between look-alike diseases) predicts susceptibility to bias.DesignThree-phase randomized experiment. Phase 1 (bias-inducing): Participants were exposed to a set of clinical cases (either hepatitis-IBD or AMI-encephalopathy). Phase 2 (diagnosis): All participants diagnosed the same cases; 4 resembled hepatitis-IBD, 4 AMI-encephalopathy (but all with different diagnoses). Availability bias was expected in the 4 cases similar to those encountered in phase 1. Phase 3 (knowledge evaluation): For each disease, participants decided (max. 2 s) which of 24 findings was associated with the disease. Accuracy of decisions on discriminating features, taken as a measure of knowledge, was expected to predict susceptibility to bias.ParticipantsInternal medicine residents at Erasmus MC, Netherlands.Main MeasuresThe frequency with which higher-knowledge and lower-knowledge physicians gave biased diagnoses based on phase 1 exposure (range 0-4). Time to diagnose was also measured.Key ResultsSixty-two physicians participated. Higher-knowledge physicians yielded to availability bias less often than lower-knowledge physicians (0.35 vs 0.97; p = 0.001; difference, 0.62 [95% CI, 0.28-0.95]). Whereas lower-knowledge physicians tended to make more of these errors on subjected-to-bias than on not-subjected-to-bias cases (p = 0.06; difference, 0.35 [CI, - 0.02-0.73]), higher-knowledge physicians resisted the bias (p = 0.28). Both groups spent more time to diagnose subjected-to-bias than not-subjected-to-bias cases (p = 0.04), without differences between groups.ConclusionsKnowledge of features that discriminate between look-alike diseases reduced susceptibility to bias in a simulated setting. Reflecting further may be required to overcome bias, but succeeding depends on having the appropriate knowledge. Future research should examine whether the findings apply to real practice and to more experienced physicians.

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