Table 1

Cognitive biases in medical decision-making relevant to paediatric RTI

Cognitive biasDescriptionExample/consequence of relevance to paediatric RTI
(1) Anticipated regretThe probability of a diagnosis with a severe outcome is overestimated due to a heightened sense of future regret in the event of missing the diagnosis.Clinicians’ fear of ‘missing the sick child’ leading to prescribing ‘just in case’,41 due to perceptions that not prescribing carries greater potential threat.
(2) Anchoring and adjustmentAssessing new cases in relation to a previous case, rather than a population baseline.Assessing a child’s RTI as severe/not in comparison to the last sick child/ren seen, rather than as a new case against a broad population baseline.
(3) Confirmation biasSelectively gathering and interpreting evidence to confirm a diagnosis, and ignoring evidence that may disconfirm it.Deciding a child needs antibiotics based on a ‘gut’ feeling and looking for reasons to prescribe.
(4) The availability biasInformation that is easily recalled is given high importance. That is, salience correlates with decision-making, regardless of the quality of the evidence. Information salience is increased by being: frequent, recent, unusual, emotive or high profile.
Research shows that simply imagining a diagnostic outcome (therefore making it salient) will raise a clinician’s subjective probability of its likelihood.42
Remembering a child with RTI symptoms who deteriorated when not offered antibiotics; media reporting of a child deteriorating after seeing their GP.
(5) RepresentativenessAssuming that what presents in clinic represents a ‘real’ state of events, includes: (A) not accounting for regression to the mean by assuming acute symptoms are representative of the illness, rather than an anomalous peak; (B) assessing only by the similarity of symptoms with possible diagnoses, and ignoring relevant base rate probabilities of diagnostic options; (C) the gambler’s fallacy of reasoning that sequential cases represent the spectrum of probabilities, for example, after four similar successive cases given diagnosis A (80% probability), similar case number 5 is given diagnosis B (20% probability), rather than being assessed independently as having 80% probability of diagnosis A.Prescribing antibiotics to a proportion of children presenting with RTI, based on symptoms on the day.
  • GP, general practitioner; RTI, respiratory tract infection.