The relationship between time to diagnose and diagnostic accuracy among internal medicine residents: a randomized experiment

Justine Staal, J Alsma, S Mamede, Andrew P Olson, G Prins-van Gilst, S. E. Geerlings, Melissa A Plesac, Michael A Sundberg, MA Frens, HG Schmidt, WW Van den Broek, Laura Zwaan

Research output: Contribution to journalArticlepeer-review

6 Scopus citations


Background: Diagnostic errors have been attributed to cognitive biases (reasoning shortcuts), which are thought to result from fast reasoning. Suggested solutions include slowing down the reasoning process. However, slower reasoning is not necessarily more accurate than faster reasoning. In this study, we studied the relationship between time to diagnose and diagnostic accuracy. Methods: We conducted a multi-center within-subjects experiment where we prospectively induced availability bias (using Mamede et al.’s methodology) in 117 internal medicine residents. Subsequently, residents diagnosed cases that resembled those bias cases but had another correct diagnosis. We determined whether residents were correct, incorrect due to bias (i.e. they provided the diagnosis induced by availability bias) or due to other causes (i.e. they provided another incorrect diagnosis) and compared time to diagnose. Results: We did not successfully induce bias: no significant effect of availability bias was found. Therefore, we compared correct diagnoses to all incorrect diagnoses. Residents reached correct diagnoses faster than incorrect diagnoses (115 s vs. 129 s, p <.001). Exploratory analyses of cases where bias was induced showed a trend of time to diagnose for bias diagnoses to be more similar to correct diagnoses (115 s vs 115 s, p =.971) than to other errors (115 s vs 136 s, p =.082). Conclusions: We showed that correct diagnoses were made faster than incorrect diagnoses, even within subjects. Errors due to availability bias may be different: exploratory analyses suggest a trend that biased cases were diagnosed faster than incorrect diagnoses. The hypothesis that fast reasoning leads to diagnostic errors should be revisited, but more research into the characteristics of cognitive biases is important because they may be different from other causes of diagnostic errors.

Original languageEnglish (US)
Article number227
JournalBMC Medical Education
Issue number1
StatePublished - Dec 2021

Bibliographical note

Funding Information:
Dr. LZ is supported by a VENI grant from the Dutch National Scientific Organization (NWO; 45116032) and an Erasmus MC Fellowship. The funding body was not involved in the design of the study and the collection, analysis, and interpretation of data and in writing the manuscript.

Publisher Copyright:
© 2021, The Author(s).


  • Cognitive bias
  • Decision making
  • Diagnostic error
  • Patient safety
  • Diagnostic Errors
  • Bias
  • Humans
  • Problem Solving
  • Internal Medicine

PubMed: MeSH publication types

  • Journal Article


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