Cognitive bias can be a serious impediment to rational decision-making by health leaders. We use a hypothetical case study to introduce some basic concepts of bias with examples of mitigation strategies. We argue that the effect of biases should be considered when making every significant administrative decision.

BACKGROUND:Dual-process psychological theories argue that clinical decision making is achieved through a combination of experiential (fast and intuitive) and rational (slower and systematic) cognitive processes.OBJECTIVE:To determine whether emergency physicians perceived their clinical decisions in general to be more experiential or rational and how this compared with other physicians.METHODS:A validated psychometric tool, the Rational Experiential Inventory (REI-40), was sent through postal mail to all emergency physicians registered with the College of Physicians and Surgeons of Ontario, according to their website in November 2009. Forty statements were ranked on a Likert scale from 1 (Definitely False) to 5 (Definitely True). An initial survey was sent out, followed by reminder cards and a second survey to non-respondents. Analysis included descriptive statistics, Student t tests, analysis of variance and comparison of mean scores with those of cardiologists from New Zealand.RESULTS:The response rate in this study was 46.9% (434/925). The respondents' median age was 41-50 years; they were mostly men (72.6%) and most had more than 10 years of clinical experience (66.8%). The mean REI-40 rational scores were higher than the experiential scores (3.93/5 (SD 0.35) vs 3.33/5 (SD 0.49), p<0.0001), similar to the mean scores of cardiologists from New Zealand (mean rational 3.93/5, mean experiential 3.05/5). The mean experiential scores were significantly higher for female respondents than for male respondents (3.40/5 (SD 0.49) vs 3.30/5 (SD 0.48), p=0.003).CONCLUSIONS:Overall, emergency physicians favoured rational decision making rather than experiential decision making; however, female emergency physicians had higher experiential scores than male emergency physicians. This has important implications for future knowledge translation and decision support efforts among emergency physicians.

In this issue of Annals, Sandhu and Carpenter 1 Sandhu H.S.S. Carpenter C.R. Clinical decisionmaking: opening the black box of cognitive reasoning. Ann Emerg Med. 2006; 48: 713-719 Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar tackle one of the tougher issues of physician performance, clinical reasoning. It is the largely unseen skill that critically defines the performance of emergency department (ED) physicians and, ultimately, the overall function and efficacy of the ED. The general public, watching popular television shows that portray the ED, could be forgiven for the impression that what is done there is primarily action oriented and procedurally skillful; instead, most of our accomplishments can be traced to the caliber of our thinking and clinical decisionmaking. In few other domains of medicine, indeed in few other domains of human endeavor, is there such variety, novelty, distraction, and chaos, all juxtaposed to a need for expeditious and judicious thinking. Good decisionmaking is the ultimate arbiter of a well-calibrated clinical performance, yet, historically, the emphasis it has received compared with other aspects of clinical performance appears wanting. Clinical Decisionmaking: Opening the Black Box of Cognitive ReasoningAnnals of Emergency MedicineVol. 48Issue 6PreviewHenry David Thoreau said, “If one advances confidently in the direction of his dreams, and endeavors to live the life he has imagined, he will meet with a success unexpected in common hours.” Full-Text PDF

Medication errors are frequent in the emergency department (ED). The unique operating characteristics of the ED may exacerbate their rate and severity. They are associated with variable clinical outcomes that range from inconsequential to death. Fifteen adult and pediatric cases are described here to illustrate a variety of errors. They may occur at any of the previously described five stages, from ordering a medication to its delivery. A sixth stage has been added to emphasize the final part of the medication administration process in the ED, drawing attention to considerations that should be made for patients being discharged home. The capability for dispensing medication, without surveillance by a pharmacist, provides an error-producing condition to which physicians and nurses should be especially vigilant. Except in very limited and defined situations, physicians should not administer medications. Adherence to defined roles would reduce the team communication errors that are a common theme in the cases described here.