American Journal of Roentgenology (AJR)

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AJR May 2018

Jason N. Itri
Wake Forest Baptist Medical Center
Winston Salem, NC

“Heuristics and Cognitive Error in Medical Imaging”

The field of cognitive science has provided important insights into mental processes underlying the interpretation of imaging examinations. Despite these insights, diagnostic error remains a major obstacle in the goal to improve quality in radiology. An article in the May 2018 issue of AJR describes several types of cognitive bias that lead to diagnostic errors in imaging and discusses approaches to mitigate cognitive biases and diagnostic error.

Co-authors Jason N. Itri, of Wake Forest Baptist Medical Center, and Sohil H. Patel, of the University of Virginia, found that radiologists rely on heuristic principles to reduce complex tasks of assessing probabilities and predicting values into simpler judgmental operations. These mental shortcuts allow rapid problem solving based on assumptions and past experiences. Heuristics used in the interpretation of imaging studies are generally helpful but can sometimes result in cognitive biases that lead to significant errors.

An understanding of the causes of cognitive biases can lead to the development of educational content and systematic improvements that mitigate errors and improve the quality of care provided by radiologists, the authors stated. Diagnostic errors commonly arise from faulty heuristics and cognitive biases that all radiologists share. Such biases can produce predictable patterns of misdiagnoses.

Awareness of the spectrum of cognitive biases is an important step toward a comprehensive strategy to learn from diagnostic errors and ultimately improve patient care. In this Q&A, Itri discusses the origins of their article and why it is important for radiologists to identify and recognize cognitive bias.

How did you and your co-authors come up with the idea?

Itri: Dr. Patel and I have a shared interest in diagnostic error and we were working on developing a new format for peer learning conferences. We were choosing cases with specific types of bias to show to colleagues in a blinded manner to determine how often they would be affected by each type of bias. We had so many good cases to choose from that we decided to write a review article on the topic.

What should readers take away from your article?

Itri: Diagnostic errors are not random chance occurrences. They are predictable and often the result of failed heuristics. In general, heuristics help us interpret imaging studies. But when they fail, we experience cognitive errors. Once we understand the role of heuristics in error, we can develop interventions that mitigate failed heuristics.

What recommendations do you have for future research as a result of this article?

Itri: There are a number of excellent articles published on diagnostic error in radiology, and cognitive biases in particular. What we need now are processes to reliably identify errors and interventions that reduce errors. For cognitive errors, there are approaches such as cognitive de-biasing and metacognition that have been proposed to reduce cognitive errors, but these have not been applied to medical imaging and tested to determine effectiveness.

Is there anything else you would like readers to know?

Itri: Yes. Despite the prevalence and negative impact of diagnostic errors, there is no initiative at the national level to reduce diagnostic errors. There are no funding sources dedicated solely to understanding and reducing diagnostic error. This is a major barrier to this type of research. I believe we need one of our major radiological societies to help develop and promote a national initiative to reduce diagnostic errors. Until we have an organized effort, it will be difficult to achieve significant improvements.


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