The Influence of Disease Severity of Preceding Clinical Cases on Pathologists’ Medical Decision Making

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Abstract

<div class="section"> <a class="named-anchor" id="S1">  </a> <h5 class="section-title" id="d293090e186">Background</h5> <p id="P1">Medical decision making may be influenced by contextual factors. We evaluated whether pathologists are influenced by disease severity of recently observed cases. </p> </div><div class="section"> <a class="named-anchor" id="S2">  </a> <h5 class="section-title" id="d293090e191">Methods</h5> <p id="P2">Pathologists independently interpreted 60 breast biopsies (one slide per case; 240 total cases in the study) in a prospective randomized observational study. Pathologists interpreted the same cases in two phases, separated by a washout period of > 6 months. Participants were not informed that the cases were identical in each phase and the sequence was reordered randomly for each pathologist and between phases. A consensus reference diagnosis was established for each case by three experienced breast pathologists. Ordered logit models examined the effect the pathologists’ diagnosis on the preceding case or the five preceding cases had on their diagnosis for the subsequent index case. </p> </div><div class="section"> <a class="named-anchor" id="S3">  </a> <h5 class="section-title" id="d293090e196">Results</h5> <p id="P3">Among 152 pathologists, 49 provided interpretive data in both phase I and II; 66 from only phase I and 37 from phase II only. In Phase I, pathologists were more likely to indicate a more severe diagnosis than the reference diagnosis when the preceding case was diagnosed as ductal carcinoma in situ (DCIS) or invasive cancer (proportional odds ratio [POR] 1.28, 95% confidence interval [CI] 1.15-1.42). Results were similar when considering the preceding 5 cases, and for the pathologists in phase II who interpreted the same cases in a different order compared to phase I (POR 1.17, 95% CI 1.05-1.31). </p> </div><div class="section"> <a class="named-anchor" id="S4">  </a> <h5 class="section-title" id="d293090e201">Conclusion</h5> <p id="P4">Physicians appear to be influenced by the severity of previously interpreted test cases. Understanding types and sources of diagnostic bias may lead to improved assessment of accuracy and better patient care. </p> </div>

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Most cited references 12

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Diagnostic concordance among pathologists interpreting breast biopsy specimens.

Joann G Elmore, Gary M Longton, Patricia A. Carney … (2015)

A breast pathology diagnosis provides the basis for clinical treatment and management decisions; however, its accuracy is inadequately understood. To quantify the magnitude of diagnostic disagreement among pathologists compared with a consensus panel reference diagnosis and to evaluate associated patient and pathologist characteristics. Study of pathologists who interpret breast biopsies in clinical practices in 8 US states. Participants independently interpreted slides between November 2011 and May 2014 from test sets of 60 breast biopsies (240 total cases, 1 slide per case), including 23 cases of invasive breast cancer, 73 ductal carcinoma in situ (DCIS), 72 with atypical hyperplasia (atypia), and 72 benign cases without atypia. Participants were blinded to the interpretations of other study pathologists and consensus panel members. Among the 3 consensus panel members, unanimous agreement of their independent diagnoses was 75%, and concordance with the consensus-derived reference diagnoses was 90.3%. The proportions of diagnoses overinterpreted and underinterpreted relative to the consensus-derived reference diagnoses were assessed. Sixty-five percent of invited, responding pathologists were eligible and consented to participate. Of these, 91% (N = 115) completed the study, providing 6900 individual case diagnoses. Compared with the consensus-derived reference diagnosis, the overall concordance rate of diagnostic interpretations of participating pathologists was 75.3% (95% CI, 73.4%-77.0%; 5194 of 6900 interpretations). Among invasive carcinoma cases (663 interpretations), 96% (95% CI, 94%-97%) were concordant, and 4% (95% CI, 3%-6%) were underinterpreted; among DCIS cases (2097 interpretations), 84% (95% CI, 82%-86%) were concordant, 3% (95% CI, 2%-4%) were overinterpreted, and 13% (95% CI, 12%-15%) were underinterpreted; among atypia cases (2070 interpretations), 48% (95% CI, 44%-52%) were concordant, 17% (95% CI, 15%-21%) were overinterpreted, and 35% (95% CI, 31%-39%) were underinterpreted; and among benign cases without atypia (2070 interpretations), 87% (95% CI, 85%-89%) were concordant and 13% (95% CI, 11%-15%) were overinterpreted. Disagreement with the reference diagnosis was statistically significantly higher among biopsies from women with higher (n = 122) vs lower (n = 118) breast density on prior mammograms (overall concordance rate, 73% [95% CI, 71%-75%] for higher vs 77% [95% CI, 75%-80%] for lower, P < .001), and among pathologists who interpreted lower weekly case volumes (P < .001) or worked in smaller practices (P = .034) or nonacademic settings (P = .007). In this study of pathologists, in which diagnostic interpretation was based on a single breast biopsy slide, overall agreement between the individual pathologists' interpretations and the expert consensus-derived reference diagnoses was 75.3%, with the highest level of concordance for invasive carcinoma and lower levels of concordance for DCIS and atypia. Further research is needed to understand the relationship of these findings with patient management.

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Perception and misperception of bias in human judgment.

Emily Pronin (2007)

Human judgment and decision making is distorted by an array of cognitive, perceptual and motivational biases. Recent evidence suggests that people tend to recognize (and even overestimate) the operation of bias in human judgment - except when that bias is their own. Aside from the general motive to self-enhance, two primary sources of this 'bias blind spot' have been identified. One involves people's heavy weighting of introspective evidence when assessing their own bias, despite the tendency for bias to occur nonconsciously. The other involves people's conviction that their perceptions directly reflect reality, and that those who see things differently are therefore biased. People's tendency to deny their own bias, even while recognizing bias in others, reveals a profound shortcoming in self-awareness, with important consequences for interpersonal and intergroup conflict.