Comic: Cognitive Bias and Other Causes of Diagnostic Errors

r.kyserFebruary 3, 2025February 3, 2025

For this month's comic, we're diving into a story of a diagnostic case gone wrong, and what might have led to it.

Panel 1:
Narration: In 2020, I spent a week in the hospital for severe anemia.
Image: An image of Rebecca, a white woman with curly brown hair, sits in a hospital bed in a hospital gown. She is hooked up to a blood bag and looks depressed.

Panel 2:
Narration: Before this, I’d spent a month trying to get tested for anemia.. I displayed a lot of symptoms:
Image: An image of Rebecca, wearing a face mask, very pale, is in the center. There are various symptoms of anemia pointing to her. They say: Lightheadedness, pulsatile tinnitus, cold even in August, Palor, fatigue, short of breath

Panel 3:
Narration: But I kept being refused as my GP was on vacation. When I tried to push the test, I was told:
Image: Three speech bubbles are below: they read as “It’s just anxiety” and “This never happens” and “It’ll be fine to wait for your GP to come back.”

Panel 4: I’d planned to wait for my GP, but after almost fainting, I got a rival medical system to run the test. I got my results that night via the phone. It went something like this:
Image: Rebecca, incredibly pale, is holding her cell phone. Her cat watches from a counter. From the phone, audio goes:
Phone: So. You are very anemic.

Panel 5:
Image: Rebecca drops her phone. Rebecca, gleeful, with her hands raised yells “Yes I’m not crazy”
From her phone, it states: “Also you need to go to the nearest ER”
Her cat watches the phone fall with alarm

Panel 6: Rebecca, with her hands still raised looks confused. She says: “Wait what?”
Her phone, now resting where the cat once was, says: “as soon as possible, actually.”

Panel 7:
Narration: Thankfully I managed to recover from my bout with vampirism, but after everything was said and done, my doctors, family, friends and myself all had the same question:
Image: Rebecca, dressed as a vampire with red eyes and fangs asks “How did this happen?”

Panel 8: While I’d only spent a month seeking out a test, I’d voiced my concerns about some symptoms I had for the past 9 months. My concerns usually were answered with the same response:
Image: Four separate scenes are shown. The upper left hand corner features a nurse with a goatee and a half shaved head. The upper right hand corner a doctor reaches out over a sink. The bottom left hand corner shows a phone. The bottom right hand corner shows three doctors discussing in front of a hospital bed. All four of them say “No one gets severe anemia at your age?”

Panel 9: (I did not respond well to that answer, once in the hospital)
Image: Rebecca, in a hospital gown, yells “YET HERE WE ARE”

Panel 10: So how did this get overlooked for so lon g? I can’t say for sure but I think cognitive bias had something to do with it.
Image: A chibi version of Rebecca speaks, with text under it labeling it as a “disclaimer.”
Rebecca’s speech bubble: “I do want to stress I think cognitive bias was one of the many potential factors in my case. I’m using my own story here not to cast blame on anyone but to provide narrative for us to explore this concept.

Panel 11:
Narration: What are cognitive biases? They are patterns of thinking, often quick or subconscious, that are prone to error (1).
Image: A picture of a video game is shown, labeled fallacy dodge. In the game, a humanoid rabbit wearing a scarf faces a frozen tundra full of hazards. Spikes on the floor are labeled as “spikes of confirmation bias” stalactites on the ceiling are labeled as “attentional bias” . a large jump with a coin on it is labeled as “authority bias”, and a pool of frozen water is labeled as “anchoring bias”

Panel 12:
Narration: Let’s take a look at some common fallacies that can be seen in medical practice
Image: Rebecca stands in front of a blackboard where “cognitive bias 101” is written in chalk

Panel 13:
Narration: Anchoring bias: relying on only one piece of information (often the 1st piece one hears) when making choices (1).
Image: a thought bubble leads to an anchor where it rests at the bottom of the ocean

Panel 14:
Narration: Confirmation bias: looking for, focusing on and recalling information that aligns with one’s beliefs
Image: A scientist cheers, holding one paper. Behind him is a large pile of papers labeled as “studies that disprove theory.”
Scientist speech bubble: Look! This study proves my theory!”

Panel 15:
Narration: The ostrich effect: ignoring or avoiding negative information
Image: An ostrich, wearing a lab coat, buries its head in the sand. Another ostrich, half off screen, looks down at it confused.

Panel 16:
Narration: Conjunction fallacy: the tendency to assume that multiple specific conditions are more likely than one general 1 (1).
Image: Zoey, a Black woman wearing glasses in a hospital gown, stands in the middle of the screen. The text around her reads as follows
Text box 1: Zoey has a cough, a fever and body aches.
Text box 2: Is it? Bullet 1: Asbestosis Bullet 2: Invasive Candidiasis Bullet 3: Lyme disease
Text box 3: Or the flu?*
Text box 4: It could be either, but it’s important to confirm it isn’t the likely answer.

Panel 17:
Narration: Posthoc Fallacy: Assuming one event caused a later event because on happened before the other assuming correlation=causation can be an example of this(1)
Image: A bald Black man in a suit looks at a line up of an ice cream cone and a virus labeled as “flu” Both hold signs. The ice cream sign says “ice cream.” The man says “Who made me sick….I did just have the ice cream recently” and the ice cream says “I’m innocent i swear”

Narration: framing bias: our perception of data depends on how it is presented(1)
Image: A woman in a hijab and a person with brown skin and brown hair sit watching television. On the television, there is an advertisement for Radiant made with Calciferol. The woman in the hijab says “Wait isn’t calciferol just vitamin D?” and the person across from them says “but it looks so fancy!”

Panel 19:
Narration: There are countless other fallacies that can interfere with decision making. But mistakes occur due to reasons other than fallacies.
Image: Rebecca, shrugging, says “think about your quality of choices when you’re tired.”

Panel 20:
Narration: Systematic issues such as understaffing and long hours can lead to increased mistakes.
Image: A nurse and a doctor stand across from each other. The doctor is holding up his hand and making an L, like people use to tell directions. They speak as follows:
Nurse: Doc, you’re exhausted. Can you even tell left from right?
Doctor: Of course, left is…uh”
Nurse: This is not inspiring confidence.

Panel 21:
Narration: When extra stressors like covid further strain such overworked systems, it’s possible that more errors can occur.
Image: The doctor and nurse stand masked surrounded by virus particles, looking more tired.

Panel 22:
Narration: Frankly, I think Covid played the largest role in my own situation. With folks tired and overworked from the pandemic, it was easier for my own case to slip through the cracks.
Image: Rebecca falling between two cliffs.

Panel 23:
Narration: Stereotypes and Implicit bias also play a role in errors, along with health disparities.
Image: Four people speak regarding health.
A women with brown skin and long black hair says: 24% of women feel a health care provider has ignored or dismissed their symptoms (2)
A latino man with curly brown hair says: 32% of hispanic patients felt they had to speak up to get proper care (3).
A black woman with her hair in two buns says : Black women are three times more likely to die in childbirth than white women (4).
A white person with orange hair and freckles in a wheelchair who has a right leg amputation says “A 2021 study found that US doctors believed disabled people have a lower quality of life than non-disabled people (5)

Panel 24:
Narration: There are efforts to address implicit bias and stereotypes in medicine but there is still a lot of work to do.
Image: Rebecca looking depressed says: I’ve heard a lot of stories from folks feeling dismissed or not listened to and I have my own that I haven’t told here.

Panel 25:
Narration: All types of bias lead not only to clinical errors but a lack of trust in medicine as a whole
Image: A snake next to a bottle of snake oil and “ms. Bettys cure all” says: Lack of trust in medicine can lead to folks buying into pseudoscience or snake oil.

Panel 26:
Narration: There is no way to truly eliminate cognitive bias, but we can try to reduce it.
Image: the nurse from earlier says “for systematic issues, we need more top down solutions.”

Panel 27:
Narration: Taking a moment to think about why we’re thinking something can help. Diagnosing fast and slow recommends we ask ourselves the following:
Image: Three doctors stand thinking. Above them are the following thought bubbles:
Doctor 1: Why do I think this?
Doctor 2: Could I be wrong?
Doctor 3: What else could this be?

Panel 28:
Narration: And maybe with those questions in mind we can prevent more patients from falling through the cracks
Image: a sidewalk is shown with flowers growing out of the cracks

SOURCES:

Coughlan JJ, Mullins CF, Kiernan TJ. Diagnosing, fast and slow. Postgrad Med J. 2021;97(1144):103-109. doi:10.1136/postgradmedj-2019-137412
Long M, Frederiksen B, Ranji U, Diep K, Published AS. Women’s Experiences with Provider Communication and Interactions in Health Care Settings: Findings from the 2022 KFF Women’s Health Survey. KFF. February 22, 2023. Accessed October 10, 2024.https://www.kff.org/womens-health-policy/issue-brief/womens-experiences-with-provider-communication-interactions-health-care-settings-findings-from-2022-kff-womens-health-survey/
Lopez CF and MH. 2. Hispanic Americans’ experiences with health care. Pew Research Center. June 14, 2022. Accessed October 10, 2024. https://www.pewresearch.org/science/2022/06/14/hispanic-americans-experiences-with-health-care/
Hill L, Artiga S, Published UR. Racial Disparities in Maternal and Infant Health: Current Status and Efforts to Address Them. KFF. November 1, 2022. Accessed October 10, 2024. https://www.kff.org/racial-equity-and-health-policy/issue-brief/racial-disparities-in-maternal-and-infant-health-current-status-and-efforts-to-address-them/
Jackson L. Doctors must challenge ableism in healthcare. BMJ. 2023;383:2968. Published 2023 Dec 20. doi:10.1136/bmj.p2968
Dahm, M. R., Williams, M., & Crock, C. (2022). ‘More than words’ – Interpersonal communication, cognitive bias and diagnostic errors. Patient Education and Counseling, 105(1), 252–256. https://doi.org/10.1016/j.pec.2021.05.012

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