key: cord-0694763-5m3gmurg authors: Hammond, M. Elizabeth H.; Stehlik, Josef; Drakos, Stavros G.; Kfoury, Abdallah G. title: Bias in Medicine: Lessons Learned and Mitigation Strategies date: 2021-01-25 journal: JACC Basic Transl Sci DOI: 10.1016/j.jacbts.2020.07.012 sha: d014a3150b27d5ae469346bf626fea4fd344cf72 doc_id: 694763 cord_uid: 5m3gmurg Cognitive bias consists of systematic errors in thinking due to human processing limitations or inappropriate mental models. Cognitive bias occurs when intuitive thinking is used to reach conclusions about information rather than analytic (mindful) thinking. Scientific progress is delayed when bias influences the dissemination of new scientific knowledge, as it has with the role of human leucocyte antigen antibodies and antibody-mediated rejection in cardiac transplantation. Mitigating strategies can be successful but involve concerted action by investigators, peer reviewers, and editors to consider how we think as well as what we think. C linical decisions and scientific decisions about choosing which articles to publish in scientific journals are both subject to biases in thought processes. In this paper article, we review the types of bias that can lead to flawed clinical decisions, as well as the delays in publishing of scientific articles that do not fit into current accepted scientific norms. Cognitive bias consists of systematic errors in thinking due to human processing limitations or inappropriate mental models (1) . Cognitive bias occurs when intuitive thinking is used to reach conclusions about information. Intuitive or "fast thinking" in modern parlance is the preferred route of decision making because it is practical and efficient. It is hardwired, subconscious, or gained by repeated experience. It is largely autonomous. As part of this intuitive thinking process, humans used heuristics, mental shortcuts learned or inculcated by evolutionary processes, to make decisions using a few relevant predictors. The counterpoint approach to intuitive thinking is analytic (mindful) thinking. In analytic thinking, logic and self-examination of attitudes about data inputs are also included. Analytic thinking is conscious, deliberate, and generally reliable (2) . Because it is a slower mental process, it is infrequently used in daily decision making. Because we all mostly operate in the mode of intuitive thinking, we all are subject to various cognitive biases in variable degrees. These biases are important because they affect human interactions with any presented information, including our processing of scientific information in publications and our evaluation of responses to the current pandemic. There are at least 100 described types of cognitive bias; the common ones of relevance to this topic are shown in Table 1 . has become an international obsession by exposing us to disease, death, economic consequences, and arguments about best options for disease control. Our biases strongly influence how we perceive this threat. The framing of information (framing bias) strongly influences our acceptance of information. When COVID-19 is framed as being a danger only to older adults, such a frame may appeal to younger adults who see their risk of infection and possibly death as being much less. When living among others who feel that the danger of COVID-19 is much less than is reported by scientists or the press, we can be affected by false consensus bias, presuming that everyone in our state or community agrees with our assessment of low risk. Such attitudes have encouraged large gatherings of people on beaches in Florida or during Mardi Gras in New Orleans in defiance of recommended social distancing practices. We promote our confirmation biases when we choose to restrict our sources of information to only those sources that agree with our social and political opinions. As Thomas Davenport recently wrote, "Emotiondriven beliefs and intuition are powerful at guiding people toward less-than-optimal decisions. By understanding our biases, we have a better chance of quieting them and moving toward better choices" (3) (Central Illustration). Although we are constantly exposed to the influence of bias in our daily lives, as physicians and scientists, we are unlikely to consider its influence in medical decision making or research. Bias has been extensively studied in the social sciences but has often been ignored in medicine (2) . There has been no systematic training of medical professionals in how bias affects decision making in either medical schools or research training programs (other than financial conflict of interest bias). However, there are recent efforts directed at increasing bias awareness in medical training programs, particularly in emergency medicine (4) . Training about bias and debiasing strategies could condition medical professionals to consciously consider how they make decisions using scientific information so that analytic thinking can become routine. Both medical school and postgraduate training emphasize team discussions as part of case presentations. Part of those discussions could include questions to address why team members prefer specific diagnoses or treatments and how they might develop a more systematic and analytic approach to the problem. We know that diagnostic failure rates can be as high as 10% to 15%; however, cognitive bias is rarely considered as a significant factor in these failures. In a systematic review of the contribution of cognitive bias to medical decision making, Saposnik et al. (5) found that cognitive bias contributed to diagnostic errors in 36% to 77% of A biased approach to decision making, although practical, may result in errors. Publication bias in medicine delays the acceptance of novel key ideas, distorts truth, and may negatively impact outcomes by hindering the development and testing of candidate therapies. Debiasing strategies, although underused, can effectively enhance self-awareness of one's thought processes away from bias and closer to objectivity and truth. Hammond et al. Favor of studies benefiting personal institution, peers, or promoting promotion in rank with a success rate of 88% (28) . A summary of published debiasing strategies, mostly involving computerized logic, is provided in Table 3 . From mindless to mindful practicecognitive bias and clinical decision making The importance of cognitive errors in diagnosis and strategies to minimize them How to Make Better Decisions about Coronavirus. 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