Cognitive disposition to respond in postgraduate trainees of general surgery at Rawalpindi Medical University

  • Muhammad Waqas Raza Rawalpindi Medical University
  • Maria Zubair
  • Mailk Irfan Ahmed
  • Rehan Ahmed Khan
Keywords: Cognitive bias, diagnostic errors, Postgraduate trainees, General surgery Clinical reasoning skills.


Introduction: Cognitive biases leading to diagnostic errors are associate with adverse outcomes and compromise patient safety and contribute to morbidity and mortality. Exploration and identification of cognitive biases have been a difficult task for the clinicians and medical educators. The literature is deficient in the identification of cognitive biases in surgical trainees. The objective of the study was to identify various cognitive biases that may negatively impact clinical reasoning skills and lead to diagnostic errors in trainees of general surgery.

Materials and Methods: A quantitative study was conducted involving 48 trainees of general surgery to explore the various cognitive biases. The questionnaire was devised and consisted of ten items devised to explore five biases. .Descriptive statistical analysis was done on SPSS 20 and the respondents with score >25 were categorized as predisposed to error scores of 20-25 were taken as a borderline and overall score of <25 was insignificant for the presence of cognitive bias.

Results: Premature closure was the most frequent cognitive bias found significant in 34 (70 %) of trainees followed by anchoring bias in 14 (58, 3 %) trainees. The relative frequencies of different biases are shown in Table 2. The mean score of the questionnaire was 22.7 (range 10 to 38) SD 7.2. Ten out of forty-eight (21%) trainees with a mean score of >25 showed a clear inclination toward cognitive errors whereas 11 (22%) with a score in the range of 21 to 25 were categorized as having an equivocal tendency towards committing an error, Whereas 27 (56%) with a score of less than 20 were less prone to cognitive errors.

Conclusion: The two most common errors seen in the study were anchoring bias and premature closure and both are related to information gathering. A larger study is required to explore the association of cognitive bias with different specialties and experience of clinicians.


1. Eichbaum Q, Adkins B, Craig-Owens L, Ferguson D, Long D, Shaver A, Stratton C. Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures to diagnostic error. Diagnosis. 2019 Aug 27; 6(3):249-57.
2. Msaouel P, Kappos T, Tasoulis A, Apostolopoulos AP, Lekkas I, Tripodaki ES, Keramaris NC. Assessment of cognitive biases and biostatistics knowledge of medical residents: a multicenter, cross-sectional questionnaire study. Medical education online. 2014 Jan 1;19(1):23646.
3. Norman G. Dual processing and diagnostic errors. Advances in Health Sciences Education. 2009 Sep 1; 14(1):37-49.
4. Norman GR, Monteiro SD, Sherbino J, Ilgen JS, Schmidt HG, Mamede S. The causes of errors in clinical reasoning: cognitive biases, knowledge deficits, and dual process thinking. Academic Medicine. 2017 Jan 1; 92(1):23-30.
5. Ogdie AR, Reilly JB, Pang MW, Keddem MS, Barg FK, Von Feldt JM, Myers JS. Seen through their eyes: residents’ reflections on the cognitive and contextual components of diagnostic errors in medicine. Academic medicine: journal of the Association of American Medical Colleges. 2012 Oct; 87(10):1361.
6. Phua DH, Tan NC. Cognitive aspect of diagnostic errors. Ann Acad Med Singapore. 2013 Jan 1; 42(1):33-41.
7. Richie M, Josephson SA. Quantifying heuristic bias: Anchoring, availability, and representativeness. Teaching and learning in Medicine. 2018 Jan 2; 30(1):67-75.
8. Rylander M, Guerrasio J. Heuristic errors in clinical reasoning. The clinical teacher. 2016 Aug; 13(4):287-90.
9. Saposnik G, Redelmeier D, Ruff CC, Tobler PN. Cognitive biases associated with medical decisions: a systematic review. BMC medical informatics and decision making. 2016 Dec; 16(1):138.
10. Singh H, Thomas EJ, Khan MM, Petersen LA. Identifying diagnostic errors in primary care using an electronic screening algorithm. Archives of Internal Medicine. 2007 Feb 12; 167(3):302-8.
11. Surry LT, Torre D, Trowbridge RL, Durning SJ. A mixed-methods exploration of cognitive dispositions to respond and clinical reasoning errors with multiple choice questions. BMC medical education. 2018 Dec 1; 18(1):277.
12. Woods NN, Mylopoulos M. How to improve the teaching of clinical reasoning: from processing to preparation. Medical education. 2015 Sep 18; 10(49):952-3.
13. Preisz A. Fast and slow thinking; and the problem of conflating clinical reasoning and ethical deliberation in acute decision‐making. Journal of paediatrics and child health. 2019 Jun; 55(6):621-4.
14. Vick A, Estrada CA, Rodriguez JM. Clinical reasoning for the infectious disease specialist: a primer to recognize cognitive biases. Clinical infectious diseases. 2013 Aug 15; 57(4):573-8.
15. Croskerry P, Singhal G, Mamede S. Cognitive debasing 2: impediments to and strategies for change. BMJ quality & safety. 2013 Oct 1; 22(Suppl 2):ii65-72.
16. Kempainen RR, Migeon MB, Wolf FM. Understanding our mistakes: a primer on errors in clinical reasoning. Medical teacher. 2003 Jan 1; 25(2):177-81.
17. Hershey JC, Baron J. Clinical reasoning and cognitive processes. Medical Decision Making. 1987 Dec; 7(4):203-11.
18. Croskerry P. From mindless to mindful practice—cognitive bias and clinical decision making. N Engl J Med. 2013 Jun 27; 368(26):2445-8.
How to Cite
Raza M, Zubair M, Ahmed M, Khan R. Cognitive disposition to respond in postgraduate trainees of general surgery at Rawalpindi Medical University. JRMC [Internet]. 30Sep.2020 [cited 22Oct.2020];24(3):240-4. Available from:

Most read articles by the same author(s)