Cognitive biases in internal medicine: a scoping review.

BACKGROUND: Medical errors account for up to 440,000 deaths annually, and cognitive errors outpace knowledge deficits as causes of error. Cognitive biases are predispositions to respond in predictable ways, and they don't always result in error. We conducted a scoping review exploring which biases are most prevalent in Internal Medicine (IM), if and how they influence patient outcomes, and what, if any, debiasing strategies are effective. CONTENT: We searched PubMed, OVID, ERIC, SCOPUS, PsychINFO, and CINAHL. Search terms included variations of "bias", "clinical reasoning", and IM subspecialties. Inclusion criteria were: discussing bias, clinical reasoning, and physician participants. SUMMARY: Fifteen of 334 identified papers were included. Two papers looked beyond general IM: one each in Infectious Diseases and Critical Care. Nine papers distinguished bias from error, whereas four referenced error in their definition of bias. The most commonly studied outcomes were diagnosis, treatment, and physician impact in 47 % (7), 33 % (5), and 27 % (4) of studies, respectively. Three studies directly assessed patient outcomes. The most commonly cited biases were availability bias (60 %, 9), confirmation bias (40 %, 6), anchoring (40 %, 6), and premature closure (33 %, 5). Proposed contributing features were years of practice, stressors, and practice setting. One study found that years of practice negatively correlated with susceptibility to bias. Ten studies discussed debiasing; all reported weak or equivocal efficacy. OUTLOOK: We found 41 biases in IM and 22 features that may predispose physicians to bias. We found little evidence directly linking biases to error, which could account for the weak evidence of bias countermeasure efficacy. Future study clearly delineating bias from error and directly assessing clinical outcomes would be insightful.

Continuing Professional Development in Rheumatology for Primary Care Clinicians: A Systematic Review.

OBJECTIVE: To determine the quality of published rheumatology-focused continuing professional development (CPD) for primary care clinicians (PCCs) for improving the care of patients with rheumatic diseases. METHODS: The authors conducted a systematic review of CPD focused on rheumatology topics for PCCs. A librarian systematically searched PubMed, Embase, Web of Science, ERIC, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Sinico. Studies were limited to those conducted in North America after 1993. An extraction form that included the Medical Education Research Study Quality Instrument and the Kirkpatrick levels of learning outcomes was created through an iterative process and applied to the included articles. RESULTS: In total, 725 articles were retrieved, of which 9 were included. Results showed that CPD was directed more at noninflammatory arthritis than inflammatory arthritis. Autoimmune diseases were underrepresented; 4 studies discussed rheumatoid arthritis, and 1 study examined rheumatologic topics broadly. Newer research tended to include multimodal approaches that combined didactic and active learning strategies, showing an evolution toward more active learning. Although online learning is increasingly popular, interventions were predominantly face-to-face, with only a single example of e-learning. Studies were predominantly of moderate quality. CONCLUSION: Published studies of rheumatology-focused CPD are moving toward more interactive teaching modalities and are typically conducted in person, although virtual options for rheumatology-focused CPD should be explored to improve access to CPD. Autoimmune disease is an uncommon topic in CPD and represents an area for future expansion. Efficacy was difficult to assess given that most of the studies assessed for learner satisfaction, knowledge acquisition, or behavior change, whereas only 1 study focused on patient outcomes.

Patellofemoral Pain Syndrome.

Patellofemoral pain syndrome (PFPS) is one of the most common causes of anterior knee pain encountered in the outpatient setting in adolescents and adults younger than 60 years. The incidence in the United States is between 3% and 6%. The cardinal feature of PFPS is pain in or around the anterior knee that intensifies when the knee is flexed during weight-bearing activities. The pain of PFPS often worsens with prolonged sitting or descending stairs. The most sensitive physical examination finding is pain with squatting. Examining a patient's gait, posture, and footwear can help identify contributing causes. Plain radiographs of the knee are not necessary for the diagnosis of PFPS but can exclude other diagnoses, such as osteoarthritis, patellar fracture, and osteochondritis. If conservative treatment measures are unsuccessful, plain radiography is recommended. Treatment of PFPS includes rest, a short course of nonsteroidal anti-inflammatory drugs, and physical therapy directed at strengthening the hip flexor, trunk, and knee muscle groups. Patellar kinesiotaping may provide additional short-term pain relief; however, evidence is insufficient to support its routine use. Surgery is considered a last resort.