Errors in clinical reasoning, known as cognitive biases, are implicated in a significant proportion of diagnostic errors. Despite this knowledge, little emphasis is currently placed on teaching cognitive psychology in the undergraduate medical curriculum. Understanding the origin of these biases and their impact on clinical decision making helps stimulate reflective practice. This article outlines some of the common types of cognitive biases encountered in the clinical setting as well as cognitive debiasing strategies. Medical educators should nurture healthy skepticism among medical students by raising awareness of cognitive biases and equipping them with robust tools to circumvent such biases. This will enable tomorrow’s doctors to improve the quality of care delivered, thus optimizing patient outcomes.

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Dehydration is a growing problem among elderly patients in hospital wards. Incidents such as those raised in the Francis Report highlight a problem that may not have been sufficiently addressed by current schemes. This improvement project aimed to identify the barriers faced by staff in improving oral hydration and to design and implement an effective solution. A 33 patient pilot study carried out at Chelsea & Westminster Hospital NHS Trust, United Kingdom, revealed that a significant proportion of patients were reported to be dehydrated on admission, with few having their hydration needs addressed. Staff cited time pressures and unclear task responsibility as the major barriers. The intervention was a Hydration Sticker education scheme. These stickers were placed on patient cups, notes and beside areas as a visual prompt for staff and family members to encourage the patient to drink. The intervention was implemented on the Acute Assessment Unit and Stroke ward through a poster campaign. The Hydration Stickers scheme resulted in a 6.5-fold increase in patients’ hydration needs being assessed and addressed. Coupled with the low implementation cost and ease of use, Hydration Stickers may be a simple, effective, transferable and sustainable solution to the problem of dehydration among elderly inpatients.

To the Editor We thank van Houwelingen et al 1 for their retrospective study exploring the efficacy and safety of intraarterial (IA) treatment in basilar artery occlusion (BAO). They reported adequate recanalization and favorable outcomes in the cohort receiving IA therapy after BAO.We commend the authors' stringent diagnostic workup to confirm the presence of BAO. However, we note that the mean age of the patient cohort was younger than 60 years, and given that this age demographic harbors fewer comorbidities compared with the older than 65 age group where stroke incidence is higher, this confers a favorable outcome regardless of the intervention. Furthermore, although some prestroke comorbidities have been accounted for, atrial fibrillation has not been considered. In patients with atrial fibrillation receiving systemic antithrombotic therapy, IA thrombolysis is contraindicated owing to the increased risk for an adverse intracranial hemorrhage, 2 thus leaving stenting as the only suitable option. Therefore, the very nature of judgement-based treatment allocation leaves the door open for potential selection bias that may significantly affect outcome measures.Although effort has been taken to categorize patency according to vessel subtype, inclusion of multiple criteria within the same category overlooks the varying pathophysiology underlying reduced patency. For example, no patency of vertebral arteries was defined as either complete occlusion, posterior inferior cerebellar artery termination, aplasia or vessel hypoplasia, or high-grade stenosis of more than 70%. Stenotic vessels are commonly caused by platelet plugs associated with atherosclerotic plaque rupture and are less likely to be successfully managed by IA urokinase alone. 2 Alternative methods of stratification may eliminate this bias.This retrospective study 1 covers a period of 9 years, a time in which stent retriever technology has considerably evolved. In particular, the Trevo device has been associated with better recanalization rates and fewer complications compared with Merci. 3 Given the inconsistencies in the device used and the fact that the Trevo device was used in most cases in this study, there may be an overestimation of benefit derived from this treatment modality as a consistent single device was not used.Restoration of cerebral perfusion alone may be insufficient to produce favorable outcomes 4 ; thus, while initial results from this study are promising, it should prompt prospective trials with a larger patient cohort to evaluate the longterm benefit of IA therapy in acute BAO.

The COVID-19 pandemic engendered an era of virtual teaching, supporting the digital aspirations outlined in The Topol Review. We recognise that to fulfil these aspirations, clinicians must be equipped with the technical skills to effectively deliver such teaching. At Kingston Hospital NHS Foundation Trust, we implemented a case-based teaching programme that improved presenters' confidence in delivering online teaching. Through our work, we offer a sustainable solution for the continued education of medical professionals while simultaneously enhancing competency in digital literacy.