How do cognitive biases compromise neurological practice?

Cognitive biases are pervasive human instincts. They are essentially shortcuts or heuristics we use all the time to make quick judgments. They crop up whenever we make decisions especially when time is limited and facts are scarce. The heuristics and biases field has burgeoned and flourished and its main exponent is the psychologist Daniel Kahneman. His book Thinking, Fast and Slow is a bestseller, and it was the subject of a recent Practical Neurology Book Club.

The general perception is that biases impair logical reasoning. There is however a lot of debate about whether heuristics and biases are evils to avoid, or virtues to apply carefully and selectively. Several authors have projected the positive aspects of biases, and the most prominent book is perhaps Gary Klein’s Sources of Power: How People Make Decisions.

How do biases and heuristics impact on neurological practice? My first clue to this was in an article in the Annals of Neurology titled How Neurologists Think: A Cognitive Psychology Perspective on Missed Diagnoses. This masterpiece explored the major biases which may lead neurologists astray when they make diagnoses. Using appropriate clinical vignettes the authors exhaustively discussed five classical biases:

Hubert Robert [Public domain], via Wikimedia Commons
Hubert Robert [Public domain], via Wikimedia Commons

A more recent article  in the journal Neurology also dwelt on the importance of shortcuts in neurological clinical reasoning. The article, aptly titled Recognising and Reducing Cognitive Bias in Clinical and Forensic Neurology, addresses some other significant biases:


Anchor by Plbmak on Flikr.
Anchor by Plbmak on Flikr.


The consensus seems to be that biases are very effective when experts use them in their specific fields. However we need to be aware when we are misapplying them. Neurologists, like all physicians, need to monitor their thinking process carefully to avoid making quick but inaccurate clinical judgments. Fortunately both articles discuss the de-biasing strategies which help to prevent the pitfalls of cognitive biases.


Black and White Hindsight by Tim J Keegan on Flikr.
Black and White Hindsight by Tim J Keegan on Flikr.


There are many other cognitive biases out there, aiding and laying traps in equal measure. Rolf Dobelli for instance lists 99 biases that may impair our thinking in his excellent The Art of Thinking Clearly. I have reviewed this and other decision-making and patient safety books on other blog:  

OK I admit it-I am making a shameful pitch for my other blog…but why not?

Proven all-time outstanding neurology textbooks

It is difficult becoming a Neurologist. It is no doubt the most diverse of the medical specialities and the field is expanding. Subspecialties are mushrooming and research studies proliferating. The diversity of expertise is breathtaking and the proliferation of research studies mind-boggling. The outpouring of papers is almost impossible to keep up with.



Thankfully we have books to keep it all in perspective. We have all been moulded by the views of the great and the wise who have sacrificed time (and families?) to make us who we are. We are all products of the books we read. Some texts are intimidating tombs, covered in several volumes; others are reassuring and handy pocket-sized aids. Some books are easy to read whilst others are a struggle. They are all good to look at on the bookshelf.

But even the concept of books is rapidly changing. It used to be sufficient to rely on the wisdom of Bryan Matthews or the thorough expositions of Maurice Victor and Raymond Adams. It was enough to refer to the single reference on the shelf; today, your book must be linked to the online version for the frequent updates. It was sufficient to quote David Marsden or Anita Harding; nowadays multi-author books are the in-thing (for good or ill).



Below is an alphabetical list of Neurology books I have looked at, and one which came highly recommended. I have linked them to their latest editions-even though I only have the older versions myself!

Clinical Guide to Epileptic Syndromes and their Treatment

Clinical Neurology (Fowler)

Clinical Neurology (Simon)

Evidence Based Neurology

Localization in Clinical Neurology

Neurological Differential Diagnosis

Neurological Emergencies

Neurology and General Medicine

Neurology in Clinical Practice

Neurology Secrets

Neuromuscular Case Studies

Neuromuscular Disorders

Neuromuscular Disorders: Treatment and Management

Neuroradiology: The Requisites

On call Neurology

Oxford Handbook of Neurology

Peripheral Neurology Case Studies

Parkinsonian Disorders in Clinical Practice

Parkinson’s Disease and Movement Disorders

Parkinson’s Disease in Practice


Some of these are better than others and I hope at sometime to review them. If this list looks intimidating, have a look at the neurology section of Waterstones! I clearly have a lot to learn and if you have a suggestion that should absolutely be on this list, (or one you strongly think shouldn’t) convince me and I will amend the list. I am keeping this list as another permanent feature of the sidebar.



You may want to follow my other blog, The Doctors Bookshelf, where I review books all doctors should read.