Table 2.

Prominent Contextual Factors in 41 Residents’ Narratives and Discussion of Cognitive Bias and Error, University of Pennsylvania, 2010^*

Contextual factor	No. (%) of narratives in which factor was reported †	Illustrative quote
Team and provider factors	38 (92.7)
Specialty service	31 (75.6)	“That’s one of the downsides of specialization, I think, that we sort of get carried away with our specific area of what we’re doing and forget—not forget, but you’re just not attuned to these other things that are going on.”
Lack of interest in the patient’s case‡	13 (31.7)	“It wasn’t urgent or emergent that we sort of find out what was going on because I think there were other patients who were critically ill.”
Hierarchy	13 (31.7)	“It’s uncomfortable to approach an attending as a resident and say, ‘Actually, I don’t agree with that plan. Let’s get more information.’”
Over-reliance on consultants	12 (29.3)	“Sometimes [when you reach out to consultants] we can sit back and say, ‘Well, Heme is on the case and— Heme always looks at smears, and if they didn’t see anything, then it isn’t a problem.’ You can really shut [down] once you say, ‘I have an expert who has said that it is not this problem.’”
Lack of confidence	7 (17.1)	“I think this was maybe my second week So I was very not confident in myself.”
System and environmental factors	33 (80.5)
Time pressure	22 (53.7)	“If we can get to a diagnosis faster, it means that you have more time to take care of other patients.”
Recent transfer§	15 (36.6)	“This problem of outside hospital [transfers] and not looking at records happens to me all the time on call. The patients come in and it just takes a while. You have so much work. It’s hard to figure out what’s in [the records].”
Poor handoff	14 (34.1)	“The patient came straight from the ED and I don’t remember a whole lot of the sign-out that I was given because it was kind of quick.”
Lack of knowledge or guidelines	14 (34.1)	“There was not a standard approach to evaluating fever in someone who’s just returning from a certain part of the world, there’s like no framework.”
Insufficient information¶	14 (34.1)	“Because the patient was not accompanied by any family members, it was hard to determine the nature of his baseline cognitive function.”
Too many patients	13 (31.7)	“Coming up with a brand new differential for each chief complaint is just not feasible when it’s your seventh admission in an ICU.”
Chaotic emergency department (ED) environment	12 (29.3)	“In the ED, you have many patients to see. You’re often required to rely on heuristics because you have limited time.”
Delayed or inaccurate test result	12 (29.3)	“We were trying to wait for the final—like, confirmatory diagnosis, but it was taking so long that we were like, ‘We should start treatment,’ because she was having fevers also.”
Patient factors	28 (68.3)
Complex illness	26 (63.4)	“Patients having multiple problems that account for their symptoms is one that’s really challenging because our tendency and the way that we’re sort of taught to think is that we have this constellation of symptoms and we’re supposed to create a unifying diagnosis.”
Vague history from patient	13 (31.7)	“This was a patient who was not a complainer and so he was very reluctant to sort of tell us as he was declining.”
Chronic illness	10 (24.4)	“The first attending signed out to the second attending, “This is a very unfortunate gentleman. He looks like he’s from Auschwitz and there’s a lot of things that are lacking in his care.’”
Bad reputation or negative connotation	9 (22.0)	“Even before seeing the patient I felt like I had a negative picture of him in my mind.”
History of substance abuse or narcotic- seeking behavior	6 (14.6)	“You see somebody on methadone and immediately you think, ‘Oh, this is going to be a battle.’ It’s going to be a big negotiation about giving pain medications, and it really can cloud your decision.”
Patient refusing services	6 (14.6)	“‘We don’t have time to do all of this if you’re not going to be cooperative. So we’re going to go with this and it seems right,’ and it was working for a period of time.”
Poor prognosis	6 (14.6)	“He was very cachectic … we were surprised to learn that he still was full code status.”

^*Comments were derived from the discussion portion of a curriculum on experiences with diagnostic error that arose from cognitive bias.

^†Subcategory numbers and percentages do not total up to main category numbers or 100% because more than one factor could be reported per narrative.

^‡Lack of interest in the patient’s case either by the entire team or any team members.

^§Recently transferred from another hospital or between levels of care in the same hospital such as intensive care unit to medical floor.

^¶For example, lack of records from a referring hospital, lack of the appropriate test results, or inability to gather the pertinent information from the patient or family.