Table 1

Educational and workplace strategies for cognitive debiasing

Strategy	Comment	Examples
Educational
training on theories of reasoning and medical decision making	Achieving improved diagnostic reasoning requires an understanding of cognitive theories about decision making and the impact of cognitive biases15–18	▸ Educational curricula covering theories of decision making, major cognitive and affective biases and their application to diagnostic reasoning19–21
Bias inoculation	A key recommendation is to teach about cognitive and affective biases and develop specific tools to test for them22–24 and for debiasing	▸ A ‘consider-the-opposite’ procedure marginally reduced anchoring in judgements of personality traits25 ▸ Cognitive forcing strategies to counteract cognitive bias showed minor effects26
Specific educational interventions	Teaching specific skills may mitigate particular biases by providing basic knowledge leading to greater insight	▸ People trained in inferential rules committed fewer base rate errors27 28 ▸ Combining a non-analytical with an analytical approach in reading ECGs improved diagnostic accuracy29
Cognitive tutoring systems	Computer-based systems can be used to construct a learner's profile of decision making and provide feedback on specific biases and strategies to mitigate them	▸ Decision monitoring software of virtual slide cases detected cognitive biases according to preset criteria30
Simulation training	Simulation may be a venue for teaching about, identifying and remediating cognitive errors31	▸ Residents experienced a simulation involving a difficult diagnosis with a cognitive error trap32
Workplace
Get more information	Heuristics and biases often arise in the context of insufficient information. Diagnostic accuracy is related to thoroughness of cue acquisition33	▸ The greater the number of attributes of a problem that can be identified, the greater the likelihood of selecting the best alternative34
Structured data acquisition	Forcing deliberate data acquisition may avoid ‘spot diagnoses’ 35 36 by ensuring that less obvious symptoms are considered	▸ Traditionally, data acquisition has been pursued by establishing a differential diagnosis list, and more recently by employing a differential diagnosis checklist tool37
Affective debiasing	Virtually all decision making involves some degree of affective influence. Many affective biases are hard-wired. Decision makers often are unaware of the affective influences on decision making38 39	▸ Overview of affective biases and recommendations for debiasing are available20
Metacognition, decoupling, reflection, mindfulness	A deliberate disengagement or decoupling from intuitive judgements and engagement in analytical processes to verify initial impressions1	▸ Deliberately reflecting upon initial diagnoses led to better diagnoses in difficult cases40 and counteracted availability bias41
Slowing down strategies	Accuracy suffers when diagnoses are made too early and improves with slowing down	▸ A planned time-out in the operating room42 43
Be more sceptical	A tendency in human thinking is to believe rather than disbelieve. Type 1 processing occurs by viewing something as more predictable and coherent than is really the case10 44	▸ No published examples
Recalibration	When the decision maker anticipates additional risks, recalibration may reduce error	▸ When bias is anticipated, (eg, medical comorbidities in psychiatric patients),45 the decision maker may recalibrate
Group decision strategy	Seeking others’ opinions in complex situations may be of value. Crowd wisdom, at times, is greater than an individual decision maker46	▸ Group rationality exceeded individual rationality in studies with experimental games in other domains47
Personal accountability	When people know their decisions will be scrutinised and they are accountable, their performance may improve	▸ Participants who knew they would be justifying their responses performed better than participants who thought that their responses were anonymous48
Supportive environments	Friendly and supportive environments improve the quality of decision making49	▸ Avoid cognitive overload, fatigue and sleep deprivation.50 Ready availability of protocols, clinical guidelines and patient care pathways reduce variance
Exposure control	Limit exposure to information that might influence judgement before an impression is formed51	▸ Although there are no published examples, some emergency physicians avoid reading nurse's notes until after they have assessed the patient. Similarly, clinicians can discourage patients from giving them another physician's diagnosis, or physician colleagues from giving their diagnosis, until they have formed their own impressions
Sparklines	Informational mini-graphics can be embedded in context in clinical data. Graphics have the potential to mitigate specific biases52	▸ A graphic outlining paediatric respiratory virus prevalence provided immediate and accurate estimates of respective base rates and trends53
Decision support systems	Support systems have been developed for clinical use54 55	▸ A reminder system reduced diagnostic errors of omission and improved diagnostic quality score55