Monick Andrew J, Zhang Xiao Chi
Sidney Kimmel Medical College at Thomas Jefferson University, Department of Emergency Medicine, Philadelphia, Pennsylvania.
West J Emerg Med. 2025 Jul 11;26(4):1055-1061. doi: 10.5811/westjem.24851.
Emergency physicians (EP) are uniquely positioned to benefit from a deeper understanding of cognitive bias, particularly in the context of limited processing time. The framing effect-the tendency to evaluate identical information inconsistently given varying methods of presentation- presents a particular challenge within emergency medicine (EM). Understanding how the presentation of clinical information affects medical decision-making is paramount, given variability in how information is received. In this study we aimed to assess whether the imposition of a cognitive frame and time pressure affected participants' differential diagnoses.
We recruited attending physicians in emergency medicine (EM) and third-year EM residents via email from our university hospital. They were asked to review two case vignettes: one consistent with pulmonary embolism (PE), the other with interstitial lung disease. Each vignette had two versions, one emphasizing features consistent with the respective diagnoses. Each pair of vignettes contained objectively identical clinical information. Subjects were randomly assigned to one of four conditions based on 1) the specific or non-specific-frame version of each case and 2) the inclusion or exclusion of time pressure. Subjects provided their top three differential diagnoses for each case. Our primary outcome measure was identification of intended diagnosis.
A total of 39 subjects completed the study. Two-sided Fisher exact tests showed that varying cognitive frames affected the likelihood of EPs identifying PE as a diagnosis of interest (P = .01). Among EPs who identified PE, the likelihood of this diagnosis leading their differential diagnosis was also related to frame (P = .01).
The results of this work reveal that cognitive frame and time pressure may independently influence diagnostic reasoning among emergency physicians, bearing implications for medical education.
急诊医生（EP）处于独特的位置，能从对认知偏差的更深入理解中受益，尤其是在处理时间有限的情况下。框架效应——即给定不同的呈现方式时，对相同信息进行不一致评估的倾向——在急诊医学（EM）中带来了特殊挑战。鉴于信息接收方式的差异，了解临床信息的呈现方式如何影响医疗决策至关重要。在本研究中，我们旨在评估认知框架的施加和时间压力是否会影响参与者的鉴别诊断。
我们通过电子邮件从我们的大学医院招募了急诊医学（EM）的主治医师和三年级EM住院医师。他们被要求审查两个病例 vignette：一个与肺栓塞（PE）一致；另一个与间质性肺病一致。每个 vignette 有两个版本，一个强调与各自诊断一致的特征。每对 vignette 包含客观上相同的临床信息。受试者根据1）每个病例的特定或非特定框架版本以及2）时间压力的纳入或排除被随机分配到四种情况之一。受试者为每个病例提供他们的前三个鉴别诊断。我们的主要结局指标是确定预期诊断。
共有39名受试者完成了研究。双侧 Fisher 精确检验表明，不同的认知框架影响了急诊医生将 PE 识别为感兴趣诊断的可能性（P = .01）。在识别出 PE 的急诊医生中，该诊断在其鉴别诊断中占主导地位的可能性也与框架有关（P = .01）。
这项工作的结果表明，认知框架和时间压力可能独立影响急诊医生的诊断推理，对医学教育具有启示意义。
