Framing of clinical information affects physicians’ diagnostic accuracy

Abstract

BackgroundFraming bias occurs when people make a decision based on the way the information is presented, as opposed to just on the facts themselves. How the diagnostician sees a problem may be strongly influenced by the way it is framed. Does framing bias result in clinically meaningful diagnostic error?MethodsWe created three hypothetical cases and asked consultants and registrars in Emergency Medicine and Internal Medicine to provide their differential diagnoses and investigations list. Two of the presentations were written two ways to frame the case towards or away from a particular diagnosis (Presentation 2 – pulmonary embolus (PE) and Presentation 3 – interstitial lung disease (ILD)) and these were randomly assigned to the participants. Both versions were however entirely identical in terms of the objective facts. Physician impressions and diagnostic plan were compared. A third presentation was identical for all and served as a control for clinician baseline ‘risk-averseness’.ResultsThere were significant differences in the differential diagnoses generated depending on the presentation’s framing. PE and ILD were considered and investigated for the majority of the time when the presentation was framed towards these diagnoses, and the minority of the time when it was not. This finding was most striking in Presentation 2, where 100%versus50% of clinicians considered PE in their diagnosis when the presentation was framed towards PE. This result remained robust when undertaking stratified analysis and logistic regression to account for differences in seniority and baseline risk-averseness— neither of the latter variables had any effect on the result.ConclusionWe demonstrate a clinically meaningful effect of framing bias on diagnostic error. The strength of our study is focus on clinically meaningful outcomes: investigations ordered. This finding has implications for the way we conduct handovers and teach juniors to communicate clinical information.

Review article: A primer for clinical researchers in the emergency department: Part XI. Inertia before investigation: Pre‐test probability in emergency medicine

“…The respondents gave answers ranging from 10% to 90%, despite receiving identical information at the start . This can lead to an undesired variety of testing rates as well as clinical outcomes …”

Conceptualizations of clinical decision-making: a scoping review in geriatric emergency medicine

“…Studies aiming to discern the impact of cognitive behaviour such as confidence, heuristics, knowledge, skills or uncertainty or contextual factors such as practices or patient behaviour, predominantly operationalized CDM as dispositional decisions or cognitive processes. Regardless of the operationalization, the vast majority of studies [41,[69][70][71][72][73][74][75][76][77][78] found that clinician cognition or contextual factors negatively affected CDM performance or the accuracy of diagnostics. Only two [79,80] found that CDM performance was unaffected by cognitive factors, however still arguing that this might not be true with more complex diseases [79].…”

“…Of these thirteen publications, all but two [43,78] operationalized CDM as cognition, describing the process itself and influencing factors. CDM was defined as a 'mental process' [21,69,82] referring to thought…”

Conceptualizations of Clinical Decision-Making: A scoping review in geriatric emergency medicine

“…Studies aiming to discern the impact of cognitive behaviour or contextual factors, predominantly operationalized CDM as dispositional decisions or cognitive processes. Regardless of the operationalization, the vast majority of studies (42,(70)(71)(72)(73)(74)(75)(76)(77)(78)(79) found that clinician cognition (i.e. con dence or heuristics) or contextual factors (i.e.…”

“…The included publications also linked increased error-risk to age-speci c biases or overreliance on heuristics (70,79,80,84). Here, speci cally the complexity of elderly patients were described to cause errors as normal clinical practice is guided by heuristics, which run the risk of simplifying complexity in urgent clinical settings (22).…”