Table 1

Video-based clinical vignette question items for cognitive bias and diagnostic error curriculum

Clinical vignetteQuestionExample(s) of correct answer(s)
Video 1A middle-aged African-American man with remote history of intravenous drug use presents to emergency department (ED) with low back pain. He is seen by a resident and diagnosed with acute lumbar strain.‘Please list three cognitive biases represented in this scene.’
  1. Anchoring

  2. Availability

  3. Blind obedience

  4. Confirmation bias

  5. Diagnostic momentum

  6. Framing effect

  7. Premature closure

  8. Visceral bias

Note: All of the cognitive biases listed above were present in the video vignette
Video 2The patient from video 1 visits primary care physician (PCP) in the office to follow-up from the ED visit. He is still complaining of back pain that is attributed to acute lumbar strain as per the ED discharge papers. Additional complaint of weak urinary stream with hesitancy attributed to opioids and prostatic hypertrophy. Later, the PCP follows up the prostate-specific antigen measured during visit and learns that the patient has been admitted to the hospital with metastatic prostate cancer and spinal cord compression.‘How did the PCP exhibit diagnostic momentum?’‘The PCP accepted the diagnosis of acute lumbar strain from gardening, without taking history or performing physical examination to challenge the working diagnosis. This led to a misattribution of the patient's urinary symptoms.’
Video 3In the hospital, an inpatient medical team discusses an admission for acute lower back pain on rounds. The patient has a history of chronic back pain, known spinal stenosis, and a history of narcotic-seeking behaviour. The attending physician exhibits several biases (visceral bias, anchoring, framing effect of the intern's presentation, confirmation bias). The team's senior resident questions the attending, prompting the team to slow down and reconsider other diagnostic possibilities, reflecting on her experience of caring for the patient from video 1 while in the hospital.‘List debiasing strategies used in this scene.’
  1. Ask ‘what else could it be?’

  2. Point out ‘what doesn't fit’

  3. Slow down/call a diagnostic timeout.

  4. Speaking up with a question to the attending to avoid blind obedience and expand differential diagnosis.