The use of deliberate reflection to reduce confirmation bias among orthopedic surgery residents

Introduction: cognitive biases might affect decision-making processes such as clinical reasoning and confirmation bias is among the most important ones. The use of strategies that stimulate deliberate reflection during the diagnostic process seems to reduce availability bias, but its effect in reducing confirmation bias needs to be evaluated.Aims: to examine whether deliberate reflection reduces confirmation bias and increases the diagnostic accuracy of orthopedic residents solving written clinical cases.Methods: experimental study comparing the diagnostic accuracy of orthopedic residents in the resolution of eight written clinical cases containing a referral diagnosis. Half of the written cases had a wrong referral diagnosis. One group of residents used deliberate reflection (RG), which stimulates comparison and contrast of clinical hypotheses in a systematic manner, and a control group (CG), was asked to provide differential diagnoses with no further instruction. The study included 55 third-year orthopedic residents, 27 allocated to the RG and 28 to the CG.Results: residents on the RG had higher diagnostic scores than the CG for clinical cases with a correct referral diagnosis (62.0±20.1 vs. 49.1±21.0 respectively; p = 0.021). For clinical cases with incorrect referral diagnosis, diagnostic accuracy was similar between residents on the RG and those on the CG (39.8±24.3 vs. 44.6±26.7 respectively; p = 0.662). We observed an overall confirmation bias in 26.3% of initial diagnoses (non-analytic phase) and 19.5% of final diagnoses (analytic phase) when solving clinical cases with incorrect referral diagnosis. Residents from RG showed a reduction in confirmation of incorrect referral diagnosis when comparing the initial diagnosis given in the non-analytic phase with the one provided as the final diagnosis (25.9±17.7 vs. 17.6±18.1, respectively; Cohen d: 0.46; p = 0.003). In the CG, the reduction in the confirmation of incorrect diagnosis was not statistically significant.Conclusions: confirmation bias was present when residents solved written clinical cases with incorrect referral diagnoses, and deliberate reflection reduced such bias. Despite the reduction in confirmation bias, diagnostic accuracy of residents from the RG was similar to those from the CG when solving the set of clinical cases with a wrong referral diagnosis.

Absence of Posttraumatic Bone Marrow Edema in the Setting of Preeclampsia

Magnetic resonance imaging is a powerful tool in the diagnosis of missed or occult fractures on radiographic and computed tomographic (CT) imaging, through the detection of bone marrow edema. Although radiologists often rely on bone marrow edema as a guide for diagnosing subtle underlying fractures, it is important to recognize its limitations as a diagnostic metric. We present a rare case demonstrating the absence of bone marrow edema after acute trauma and confirmed Lisfranc fracture in a patient with preeclampsia and propose an interesting physiologic mechanism to explain this manifestation.

An audit of the polytrauma fracture detection rate of clinicians evaluating lodox statscan bodygrams in two South African public sector trauma units

BACKGROUND

Increasing global demand for specialized radiological investigations has resulted in delayed or non-reporting of plain trauma radiographs by radiologists. This is particularly true in resource-limited environments, where referring clinicians rely largely on their own radiographic interpretation. A wide accuracy range has been documented for non-radiologist reporting of conventional trauma radiographs. The Lodox Statscan whole-body digital X-ray machine is a relatively new technology that poses unique interpretive challenges. The fracture detection rate of trauma clinicians utilizing this modality has not been determined.

OBJECTIVE

An audit of the polytrauma fracture detection rate of clinicians evaluating Lodox Statscan bodygrams in two South African public-sector Trauma Units.

METHODS

A retrospective descriptive study of imaging data of Cape Town Level 1-equivalent public-sector Trauma Units during March-April 2015. Statscan bodygrams acquired for adult polytrauma triage were reviewed and correlated with follow-up imaging and patient records. Missed fractures were stratified by body part, mechanism of injury and ventilatory support. The fracture detection rate was determined with 95% confidence. The Generalised Fischer Exact Test assessed any association between the fracture site and failure of detection. Specialist orthopaedic review assessed the potential need for surgical management of missed fractures.

RESULTS

227 patients (male = 193, 85%; mean age: 33 years) were included; 195 fractures were demonstrated on the whole-body triage projections. Lower limb fractures predominated (n = 66, 34%). The fracture detection rate was 89% (95% CI = 86-93%), with the site of fracture associated with failure of detection (p = 0.01). Twelve of 21 undetected fractures (57%) involved the elbow or shoulder girdle. All elbow fractures (n = 3, 100%), more than half the shoulder girdle fractures (9/13,69%) and 12% (15/123) of extremity fractures were undetected. One missed fracture (1/21,4.7%) unequivocally required surgical management, while a further 7 (7/21, 33.3%) could potentially have benefitted from surgery, depending on follow-up imaging findings.

CONCLUSION

This is the first analysis of the accuracy of bodygram polytrauma fracture detection by clinicians. Particular review of the shoulder girdle, elbow and extremities for subtle fractures, in addition to standardized limb positioning, are recommended for improved diagnostic accuracy in this setting. These findings can inform clinician training courses in this domain.