Needed: consensus and classification for terms used in cognitive, forensic and clinical bias discussions.

All evolving disciplines have long grappled with nomenclature inconsistencies. Precise terminology facilitates communication among individuals, clinicians, academics and researchers. To arrive at definitions, the concepts underlying basic scientific vocabularies must be universally acceptable to all users. This is not always easy. Tarachow cautioned in 1965 about how contractions and abbreviations, "…eliminated practically all the associations connected with the original title and did not at all have the evocative impact of the complete word or title"[1] (Tarachow, 1965). Clinical medicine has designed and used with some success disease-diagnosis based classification systems. Forensic science, as does clinical medicine, relies on cognitive processes for its mission to achieve expert accuracy. Both fields are vulnerable to biases and errors in cognition, more so when no terminology standards exist. It is time to develop a nomenclature system in the field of cognitive bias and cognitive errors. This system should build transdisciplinary understanding, at least during expertise-based undertakings in forensic and clinical sciences.

Blinding or information control in diagnosis: could it reduce errors in clinical decision-making?

Background Clinical medicine has long recognized the potential for cognitive bias in the development of new treatments, and in response developed a tradition of blinding both clinicians and patients to address this specific concern. Although cognitive biases have been shown to exist which impact the accuracy of clinical diagnosis, blinding the diagnostician to potentially misleading information has received little attention as a possible solution. Recently, within the forensic sciences, the control of contextual information (i.e. information apart from the objective test results) has been studied as a technique to reduce errors. We consider the applicability of this technique to clinical medicine. Content This article briefly describes the empirical research examining cognitive biases arising from context which impact clinical diagnosis. We then review the recent awakening of forensic sciences to the serious effects of misleading information. Comparing the approaches, we discuss whether blinding to contextual information might (and in what circumstances) reduce clinical errors. Summary and outlook Substantial research indicates contextual information plays a significant role in diagnostic error and conclusions across several medical specialties. The forensic sciences may provide a useful model for the control of potentially misleading information in diagnosis. A conceptual analog of the forensic blinding process (the "agnostic" first reading) may be applicable to diagnostic investigations such as imaging, microscopic tissue examinations and waveform recognition. An "agnostic" approach, where the first reading occurs with minimal clinical referral information, but is followed by incorporation of the clinical history and reinterpretation, has the potential to reduce errors.

Vestibular evoked myogenic potential testing: Payment policy review for clinicians and payers.

PURPOSE OF REVIEW: A recent American Academy of Neurology Evidence-Based Practice Guideline on vestibular myogenic evoked potential (VEMP) testing has described superior canal dehiscence syndrome (SCDS) and evaluated the merits of VEMP in its diagnosis. SCDS is an uncommon but now well-recognized cause of dizziness and auditory symptoms. This article familiarizes health care providers with this syndrome and the utility and shortcomings of VEMP as a diagnostic test and also explores payment policies for VEMP. RECENT FINDINGS: In carefully selected patients with documented history compatible with the SCDS, both high-resolution temporal bone CT scan and VEMP are valuable aids for diagnosis. Payers might be unfamiliar with both this syndrome and VEMP testing. SUMMARY: It is important to raise awareness of VEMP and its possible indications and the rationale for coverage of VEMP testing. Payers may not be readily receptive to VEMP coverage if this test is used in an undifferentiated manner for all common vestibular and auditory symptoms.

Diagnosing Crime and Diagnosing Disease-II: Visual Pattern Perception and Diagnostic Accuracy.

Previously, we reviewed how general cognitive processes might be susceptible to bias across both forensic and clinical fields, and how interdisciplinary comparisons could reduce error. We discuss several examples of clinical tasks which are heavily dependent on visual processing, comparing them to eyewitness identification (EI). We review the "constructive" nature of visual processing, and how contextual factors influence both medical experts and witnesses in decision making and recall. Overall, studies suggest common cognitive factors uniting these visual tasks, in both their strengths and shortcomings. Recently forensic sciences have advocated reducing errors by identifying and controlling nonrelevant information. Such efforts could effectively assist medical diagnosis. We suggest potential remedies for cognitive bias in these tasks. These can generalize across the clinical and forensic domains, including controlling the sequencing of contextual factors. One solution is an agnostic primary reading before incorporation of a complete history and interpretation.

Diagnosing Crime and Diagnosing Disease: Bias Reduction Strategies in the Forensic and Clinical Sciences.

Cognitive effort is an essential part of both forensic and clinical decision-making. Errors occur in both fields because the cognitive process is complex and prone to bias. We performed a selective review of full-text English language literature on cognitive bias leading to diagnostic and forensic errors. Earlier work (1970-2000) concentrated on classifying and raising bias awareness. Recently (2000-2016), the emphasis has shifted toward strategies for "debiasing." While the forensic sciences have focused on the control of misleading contextual cues, clinical debiasing efforts have relied on checklists and hypothetical scenarios. No single generally applicable and effective bias reduction strategy has emerged so far. Generalized attempts at bias elimination have not been particularly successful. It is time to shift focus to the study of errors within specific domains, and how to best communicate uncertainty in order to improve decision making on the part of both the expert and the trier-of-fact.

Clinical exome sequencing in neurologic disease.

PURPOSE OF REVIEW: The landscape of genetic diagnostic testing has changed dramatically with the introduction of next-generation clinical exome sequencing (CES), which provides an unbiased analysis of all protein-coding sequences in the roughly 21,000 genes in the human genome. Use of this testing, however, is currently limited in clinical neurologic practice by the lack of a framework for appropriate use and payer coverage. RECENT FINDINGS: CES can be cost-effective due to its high diagnostic yield in comparison to other genetic tests in current use and should be utilized as a routine diagnostic test in patients with heterogeneous neurologic phenotypes facing a broad genetic differential diagnosis. CES can eliminate the need for escalating sequences of conventional neurodiagnostic tests. SUMMARY: This review discusses the role of clinical exome sequencing in neurologic disease, including its benefits to patients, limitations, appropriate use, and billing. We also provide a reference template policy for payer use when considering testing requests.

Symptom exaggeration and symptom validity testing in persons with medically unexplained neurologic presentations.

Neurologists often evaluate patients whose symptoms cannot be readily explained even after thorough clinical and diagnostic testing. Such medically unexplained symptoms are common, occurring at a rate of 10%-30% among several specialties. These patients are frequently diagnosed as having somatoform, functional, factitious, or conversion disorders. Features of these disorders may include symptom exaggeration and inadequate effort. Symptom validity tests (SVTs) used by psychologists when assessing the validity of symptoms and impairments are structured, validated, and objectively scored. They could detect poor effort, underperformance, and exaggeration. In settings with appropriate prior probabilities, detection rates for symptom exaggeration have diagnostic utility. SVTs may help in moderating expensive diagnostic testing and redirecting treatment plans. This article familiarizes practicing neurologists with their merits, shortcomings, utility, and applicability in practice.

Complementary and alternative medicine in multiple sclerosis: Payment policy perspectives.

This article identifies payment policy perspectives of the American Academy of Neurology's guideline on complementary and alternative medicine (CAM) in multiple sclerosis (MS). The guideline is a reliable repository of information for advocating or not recommending certain CAM treatments in MS. It eases the burden of searching for information on each separate CAM treatment. It frequently emphasizes the need for patient counseling. To provide such generally undervalued, but needed, cognitive services, neurologists could use advanced practice providers and patient-friendly visual aids during or between visits. They should also rely on evaluation and management codes that recognize time spent predominantly on counseling or coordination of care. The guideline's categorization of probable effectiveness of certain therapies will not influence coverage decisions because payers do not generally cover CAM therapies.

Recognizing and reducing cognitive bias in clinical and forensic neurology.

In medicine, cognitive errors form the basis of bias in clinical practice. Several types of bias are common and pervasive, and may lead to inaccurate diagnosis or treatment. Forensic and clinical neurology, even when aided by current technologies, are still dependent on cognitive interpretations, and therefore prone to bias. This article discusses 4 common biases that can lead the clinician astray. They are confirmation bias (selective gathering of and neglect of contradictory evidence); base rate bias (ignoring or misusing prevailing base rate data); hindsight bias (oversimplification of past causation); and good old days bias (the tendency for patients to misremember and exaggerate their preinjury functioning). We briefly describe strategies adopted from the field of psychology that could minimize bias. While debiasing is not easy, reducing such errors requires awareness and acknowledgment of our susceptibility to these cognitive distortions.

Vagus nerve stimulation in the treatment of epilepsy: Payment policy perspectives.

This article is presented as a companion to the recent American Academy of Neurology (AAN) guideline update on use of vagus nerve stimulation (VNS) for treating epilepsy. The guideline update reaffirms the efficacy of VNS for intractable epilepsy. Whereas it upholds the value of VNS for its originally approved indications, the guideline reminds us of existing evidence gaps and unmet research needs. This companion identifies ambiguities in the definition of intractable epilepsies and discusses the use of VNS in children under age 12 years and in persons with intellectual disabilities (mental retardation). Many payers require prior authorization and fulfillment of criteria for coverage of VNS. This article provides guidance and background information to reduce obstacles for coverage, especially where uncertainties exist and levels of evidence are lower.

An analysis of AAN's evidence-based guideline for IVIg use in neurologic disorders: Provider impact and payer perspectives.

Health insurers look for reliable, published evidence such as evidence-based guidelines put forth by medical specialty societies to craft their coverage policies. These guidelines generate both beneficial and controversial consequences on policies. Coverage policies aim to address the most typical clinical presentations. The American Academy of Neurology guideline for IV immunoglobulin strengthens the case for coverage when it is used to treat Guillain-Barré syndrome and chronic inflammatory demyelinating polyradiculoneuropathy. The guideline is less likely to strengthen coverage for several other diagnoses with lower levels of evidence. The responsibility to clarify specific situations when patient need falls outside of what is considered to be routine evaluation or treatment rests heavily on the physician. Advice on appealing an unfavorable coverage decision is also provided to the reader.