A recent commentary in the New England Journal of Medicine focused on the high level of medical diagnostic errors made by physicians. Frighteningly, a pulmonary embolus was misdiagnosed in 55 percent of fatal cases studied. Another recent study of individuals living in a home setting demonstrated that psychiatrists diagnosed depression in, and prescribed more anti-depressant medication for, older white patients as compared to older black patients with the same symptoms. Yet, other serious mental illnesses like schizophrenia and other psychoses were diagnosed more frequently among minority populations compared to their white counterparts, leading to over-prescription of potent medications and stigma.
The author of the NEJM piece argues that, among the many reasons for these errors/decisions in clinical decision-making is cognitive bias. Instead of relying on critical analysis with slow and deliberative thinking, doctors rely too heavily on instinctual thinking -- unaware of the need to combine these two thought modalities -- intuition and critical analysis.
The solution is not simple: Physicians need to recognize the biases they bring to decision-making (itself not an easy task, as folks are often not self-aware), and then they need to be directed to increased critical thinking skills through added educative efforts before, during and after medical school. And, there needs to be immediate "de-biasing" to reverse the current error-prone decisions doctors make.
This commentary captured my attention immediately because of several very recent examples of cognitive biases I experienced in the educational arena -- experiences that impact the quality of and educational outcomes for vulnerable students. In the interest of full disclosure, I have merged events to preserve the identity of those singled out -- although President Obama felt no such need to disguise his personal experiences with bias.
I have both heard about and witnessed caring staff members speaking and acting in ways that leave the impression that they are suffering from cognitive biases. We recently had an on-campus meeting to discuss interventions that can be developed for our many at-risk students. At the gathering, it was obvious as soon as the conversation started that not everyone was of like mind as to why vulnerable students go off track.
To be sure, there are many explanations. But, one staff member's eyes rolled at the mention of students who were struggling academically. We have to ask, she observed, "Are students struggling because they aren't really trying and are playing instead or perhaps are just gaming the system to get more time to do their work?"
From this staff person's perspective, there was a presumption that there were no "suitable" explanations for vulnerable students' failures other than those within the students' control. Culture, lack of comfort, family issues, depression, stress -- none of these seemed to be implicated. There was no sense that the staff person's interventions themselves had missed the mark. In short, the students, not the institution, were at fault. Cognitive bias. Ouch.
To the second point, I recently attended a lunchtime fundraising event for a wonderful organization. The organization had created the seating and I was seated with its CEO, the president of a re-emerging nonprofit organization, a prominent artist and the president of an elite, private university. Midway through the meal, the sponsoring organization's leader turned to the president of the elite educational institution and said, "let me introduce you to some key individuals," upon which they both got up and excused themselves from the table. I have no doubt but these key individuals were people with the capacity to make large donations. Perhaps it goes without saying but I was not invited along.
I am sure there were many reasons for the foregoing but I suspect that part of the explanation was that as the leader of a non-elite, non-selective small college, I did not immediately have "rank." Introducing my institution and me would not have impressed these big givers, and the event's CEO would not get many kudos for prestigious invitees.
While personally hurtful at some level, what really bothered me was the not so hidden belief that non-elite institutions have both non-elite leaders and non-elite students and thus are not deserving of largess, even though they and their institutions are vastly more in need. Even small dollars can make a big difference to a less established institution like Southern Vermont College. Another ouch.
The NEJM article suggests solving cognition errors by educating prospective and current physicians on critical thinking skills. I actually think that is what we are trying to do across the educational spectrum -- providing students with more than subject matter competency. We want to do more than teach to the test, although we need to get vastly better at teaching critical thinking and problem-solving skills.
Within my own institution, we are trying some activities and events for students, faculty and staff to prevent cognitive bias build-up and to "de-bias" existing cognitive errors. While we still lack quality longitudinal empirical assessment of these approaches, I am satisfied that doing something is preferable to doing nothing.
We are offering intensive diversity education to faculty and staff again this coming academic year. We offer students a course -- taught by the provost -- that allows SVC and selected high school students to study their own matrilineal and patrilineal DNA as a way of appreciating both the sameness and differences among us, thereby undercutting biases. This course, with the guidance of Professor Henry Louis Gates, shows us that who we "are" is not always consonant with who we think we are. I still remember students finding out lineage that changed how they perceived themselves and others by finding out they are part-African or part-Jewish or part-Middle Eastern.
At the end of the day, the NEJM article serves as a reminder that we all suffer from cognitive biases, even the most educated among us, and we would be well served spending some time "de-biasing" ourselves as individuals. Our own cognitive bias impacts others but also our perception of ourselves. When we become better aware, then, like physicians, we can reduce the error rates in thinking about colleges/universities, our current and prospective students and ourselves -- for the betterment of individuals, institutions and the larger public good.