Medical residents’ experiences with group biases in medical decision making: a qualitative study

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Choi, Nada Mhaimeed, Dabia Al-Mohanadi, Mai A. Mahmoud This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4025933/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Systematic biases in group decision making (i.e., group biases) may result in suboptimal decisions and potentially harm patients. It is not well known how impaired group decision making in patient care may affect medical training. This study aimed to explore medical residents’ experiences and perspectives regarding impaired group decision making and the role of group biases in medical decision making. Methods This study used a qualitative approach with thematic analysis underpinned by a social constructionist epistemology. Semi-structured interviews of medical residents were conducted at a single internal medicine residency program. Residents were initially asked about their experiences with suboptimal medical decision making as a group or team. Then, questions were targeted to several group biases (groupthink, social loafing, escalation of commitment). Interviews were transcribed and transferred to a qualitative data analysis software. Thematic analysis was conducted to generate major themes within the dataset. Results Sixteen interviews with residents revealed five major themes: ( 1 ) hierarchical influence on group decision making; ( 2 ) group decision making under pressure; ( 3 ) post-call challenges in decision making; ( 4 ) interactions between teamwork and decision making; and ( 5 ) personal and cultural influences in group decision making. Subthemes were also identified for each major theme. Most residents were able to recognize groupthink in their past experiences working with medical teams. Residents perceived social loafing or escalation of commitment as less relevant for medical team decision making. Conclusions Our findings provide unique insights into the complexities of group decision making processes in teaching hospitals. Team hierarchy significantly influenced residents’ experiences with group decision making—most group decisions were attributed to consultants or senior team members, while lower ranking team members contributed less and perceived fewer opportunities to engage in group decisions. Other factors such as time constraints on decision making, perceived pressures from other staff members, and challenges associated with post-call days were identified as important barriers to optimal group decision making in patient care. Future studies may build upon these findings to enhance our understanding of medical team decision making and develop strategies to improve group decisions, ultimately leading to higher quality patient care and training. bias group decision making groupthink team dynamics Background Medical decision making is an essential component of healthcare and training. It is a complex and dynamic process that is influenced by a wide array of clinical factors (e.g., clinical presentation, disease probabilities, test characteristics, assessment of benefits and harms) and non-clinical factors (e.g., patient preferences and values, characteristics of the clinician and practice setting).( 1 – 4 ) An important consideration is that many medical decision making in diagnosis and treatment processes involve the collaboration of multiple individuals—broadly called group decision making.( 5 , 6 ) This is especially critical for training skills in medical decision making, which inherently occurs within groups or teams (terms we use interchangeably in this context). This ranges from one-on-one interactions between a trainee and a preceptor to the multifaceted dynamics of a medical team. Yet, the study of group decision making in medical training is relatively underdeveloped. A common perception of group decision making is that it leads to better decisions by drawing from multiple perspectives, experiences, and areas of expertise. This "wisdom of crowds" has been conceptualized as the collective intelligence that arises when imperfect judgments are aggregated.( 7 ) In medical decision making, collective intelligence has been demonstrated to improve diagnostic accuracy and reduce diagnostic errors by pooling or aggregating multiple physicians’ judgments.( 8 – 11 ) However, collective intelligence in diagnosis has typically pooled independent judgments without considering the effects of group interactions (or group dynamics). Certain group dynamics may hinder effective decision making, and some argue that this threatens all group decision making processes.( 12 , 13 ) Group biases (or group decision making biases) have been described as systematic patterns of deviation from rational judgment and decision making affecting groups that result in poor decisions.( 14 ) For example, brainstorming in groups may lead to fewer ideas and less productivity ( 15 – 18 ), which might occur due to a group bias known as ‘social loafing’ (when some team members give less effort to problem solving in a group setting).( 19 ) It is unknown how impaired group decision making in patient care may affect medical trainees and whether certain group biases play an important role. Thus, this interview study aimed to explore medical residents’ experiences and perspectives regarding impaired group decision making and the role of group biases in medical decision making. We focus on medical residents because they are uniquely positioned on the ‘frontline’ of decision making processes in teaching hospitals. They work closely with senior doctors or consultants, other health professionals, and patients, and exclusively make decisions in group settings, under supervision and/or in collaboration with others. We formulated the following research questions: What are the lived experiences of medical residents with group decisions that were suboptimal in patients’ care? What are medical residents’ perspectives on group biases in the context of medical decision making? Insights from this study may inform future studies and interventions that improve group decision making processes for patient care and training. Methods Study design This study used a qualitative approach with thematic analysis underpinned by a social constructionist epistemology, which views knowledge (what we understand and know about the world) as co-created through social processes and focuses on how social interactions shape our understanding of the world.( 20 , 21 ) Individual semi-structured interviews were conducted to facilitate deeper discussion of complex questions and allow participants to share detailed accounts of experiences, interpretations, and perspectives.( 22 ) This study was conducted at Weill Cornell Medicine-Qatar (WCM-Q) and the affiliated Hamad Medical Corporation (HMC). The study was approved by the WCM-Q and HMC Institutional Review Boards (Weill Cornell Medicine-Qatar IRB 22 − 00001 and the Hamad Medical Corporation reliance acknowledgement MRC-01022045). Participants Internal medicine residents at HMC were recruited by e-mail and provided information outlining study details. Enrolled participants were those who voluntarily responded, completed the consent process as per the protocol, and provided signed informed consent. HMC is the main healthcare provider in the state of Qatar, comprising of 12 hospitals that provide all levels of care. HMC is the main affiliate to WCM-Q, the first medical school established in Qatar where many HMC consultants have affiliate faculty appointments. HMC hospitals serve as the main teaching hospitals in Qatar that offer graduate medical education. Clinicians and trainees at HMC represent a diversity of national backgrounds from the Middle East, North Africa, Asia, Europe, and North America. In this study, a total of 16 medical residents were enrolled and then interviewed, including 5 first-year, 5 second-year, and 6 third-year residents. 8 were females. Data collection In-depth, semi-structured interviews in English were conducted over 5 months, from February 24 to June 6, 2023. Interviews were conducted by MAM via video conferencing due to the COVID-19 restrictions. Each interview lasted approximately 30 to 45 minutes. Audio recordings of all interviews were transcribed and transferred to a qualitative data analysis software (Quirkos, version 2.5.3). We developed an interview guide based on a literature review and research team expertise. A general question was initially posed during the interview regarding medical residents’ experiences with suboptimal medical decision making as a group or team. Then, questions targeted to several group biases were asked after providing a definition of each (see more details in the next section). As interviews progressed, in-depth questions were also posed, such as “Can you explain in more detail?”, “What were the dynamics in the group that contributed to [that]?”, and “Are there approaches that might avoid [that]?”. At the end of every interview, residents were asked “What else do you think is critical for us to know about group decision making in medicine that we have not covered?”. The data collection ended when saturation of themes was reached. ( 23 ) Group biases To ask medical residents about their perspectives and experiences with group biases, we used a framework and definitions provided by Mannion and Thompson of three group biases drawn from social and organizational psychological studies that are relevant to patient safety and medical decision making: ‘groupthink’, ‘social loafing’, and ‘escalation of commitment’.( 24 ) We did not include a fourth group bias known as ‘group polarization’ given similarities in its roots and antecedents with groupthink, and to ensure an in-depth interview could be completed within a reasonable time period. Groupthink is a bias that occurs when highly cohesive groups with strongly connected members inhibit the expression of individual opinions. In such cases, group harmony may take precedence over effective decision making. Group members desire for harmony or conformity and override their motivation realistically to propose alternative courses of action. An example provided by Mannion and Thompson is when staff members agree with an idea proposed by a senior doctor, who is viewed as a charismatic leader with a national and international reputation for research, despite uncertain evidence for or against the idea, and little time is given to scrutinizing the idea. Social loafing is the phenomenon of a group member giving less effort or reducing motivation to achieve a goal when working in a group than when working alone. An example provided by Mannion and Thompson is when a multi-ward clinical audit of nursing records finds that one ward has failed to collect audit data due to the senior nurse’s assumption that her three deputies would complete the audit. Escalation of commitment refers to the tendency for individuals or groups to continue to support a course of action despite evidence that it is failing. Mannion and Thompson provide an example in terms of committing further resources to a failing investment in a new information technology infrastructure. An example more directly related to medical decision making might be continuing a therapy despite a patient’s clinical deterioration rather than considering alternative treatment options or re-considering alternative diagnoses. Data analysis Thematic analysis of the dataset was conducted by two researchers (JJC, MAM) within Quirkos software.( 25 , 26 ). Before coding, both researchers read all interview transcripts in an effort to familiarize themselves with the data. Then, codes were independently assigned to relevant data segments (words, phrases, sentences) in the first five transcripts. Afterwards, they met to incorporate codes and discuss discrepancies in developing a preliminary coding framework. The researchers used the coding framework on additional transcripts, added new codes as they were identified, and met several times to reach consensus on suggested codes and how these were assigned to data. After ten transcripts, no new codes emerged and a full coding framework was used to code all interviews (including previously coded transcripts). JJC reviewed all codes to search for categories of codes, identify patterns, and search for relationships with the original research questions. In doing so, JJC generated an initial set of themes. MAM read all transcripts, codes, and proposed themes to triangulate and establish agreement. In the final phase, themes were shared and discussed with all authors to prepare a report of the study findings. Reflexivity: role of researchers JJC, DA, and MAM are medical educators and researchers at WCM-Q (DA and MAM) and its home WCM campus in New York City (JJC). JJC has no role with medical residents at HMC. DA and MAM have medical education leadership roles at WCM-Q and HMC; DA primarily interfaces with medical residents as a program director, and MAM primarily interfaces with medical students as a clerkship core faculty. During the conduct of this study, NM was a medical student at WCM-Q. NM and DA were not involved in data collection or data analysis, and instead, engaged in member checking by reviewing themes (from the perspectives of both a trainee and supervisor) to enhance the accuracy and credibility of the research findings. MAM conducted all interviews and maintained an awareness that her role might impact residents’ willingness to share experiences. Throughout their analysis of the dataset, JJC and MAM maintained awareness of potential bias and actively sought evidence of contrary views through reflection and discussion during regular researcher meetings. Results Sixteen interviews with medical residents revealed insights on suboptimal group decision making within patient care drawn from their lived experiences working in teams. Medical residents recalled instances of suboptimal group decisions for four domains of medical decision making: ( 1 ) diagnosis (diagnostic errors); ( 2 ) treatment (treatment errors); ( 3 ) discharge (premature discharge); ( 4 ) monitoring (delayed recognition of clinical deterioration). The influence of the consultant (i.e., attending physician) on the medical team played a ubiquitous role in suboptimal group decision making. Other team members that were mentioned as part of the group decision making process in these cases were other residents on the team, consulting physicians from other specialties, and in some cases, the case manager or social worker (as part of the discharge process) and the patient or family members themselves (as part of shared decision making). Notably, nurses were not mentioned by any resident in their recall of past experiences with suboptimal group decision making. There were mixed findings in medical residents’ ability to recognize various group biases in medical decision making. Groupthink was the most readily identified by residents. In all cases of groupthink, residents found themselves following the decision or opinion of the consultant. Only two residents had difficulty recalling an experience representative of groupthink. For social loafing and escalation of commitment biases, few residents could identify these in their experience with patient care teams (three and five residents, respectively). Several residents viewed these group biases as not plausible in medical decision making given individual motivations and team awareness of promoting quality and safety in patient care. Some residents suggested that decreased participation during team rounds might be misconstrued as social loafing, when in fact it reflects varying roles and responsibilities (e.g., early learners leaning on the experience and expertise of senior team members) or a division of labor (individual work versus tasks requiring collaboration). Anecdotes in which social loafing was identified included a resident’s lack of interest in a specific rotation, senior residents ‘sitting back’ at the end of the year, and a consultant with an extremely ‘hands off’ approach with residents. For most cases in which escalation of commitment was perceived as a contributor to suboptimal group decisions, faulty diagnostic reasoning (e.g, not questioning the accepted diagnosis, failure to consider other possible diagnoses) played a prominent role. For example, a medical team continued pursuing a diagnosis (e.g., tuberculosis workup) and failed to change an accepted diagnosis (e.g., heart failure exacerbation) despite repeated negative testing and worsening of the patient’s condition, respectively. For one resident, escalation of commitment was most noticeable in management plans, sticking with a treatment plan or protocol despite lack of efficacy. In addressing medical residents’ perspectives on group biases in medical decision making, 5 themes with subthemes were identified (Table). We present and discuss these below with representative quotes. Table. Major themes and subthemes summarizing medical residents’ experiences with and perspectives on group biases in medical decision making. Theme 1: Hierarchical influence on group decision making Subthemes Top-down decision making Conformity vs autonomy Perceived value in judgments and decisions Theme 2: Group decision making under pressure Subthemes Time pressures during work rounds Pressure to discharge patients Theme 3: Post-call challenges in decision making Subthemes High patient volume Increased workload Fatigue in decision making Theme 4: Interactions between teamwork and decision making Subthemes Communication Cohesion Mutual support Theme 5: Personal and cultural influences in group decision making Subthemes Individual personalities Personal experience and confidence Cultural influences Theme 1: Hierarchical influence on group decision making. Most residents viewed group decision making in patient care as a top-down process that starts with the consultant. Residents felt there are few opportunities challenge the consultant on decisions they have made, thus withholding their opinions or questions on any given decision. The decision is made by the most senior member of the team, so we cannot do much about it. Due to the hierarchy in medical decision making, residents perceived a tension between conforming to the group decision and expressing individual thoughts. [Sometimes] you just go with the flow and you try not to disrupt the group with an individual thought. You just go with the flow and do what you're supposed to do. You're not even allowed to question [the consultant’s decision]. Because everyone does this, and for your peace of mind, you don't argue a lot. Most residents felt that a lower rank in the medical team hierarchy was associated with lower value placed by more senior team members on their judgments and decisions. On the other hand, other residents reported that some consultants did value the input of the lowest ranking team members. Because of your title as a ‘PGY-1’, no one takes your ideas seriously…Hierarchy is the main problem. Theme 2: Group decision making under pressure. Residents described several external pressures that influenced both the group decision making process and final decisions made as a group. For example, time constraints on work rounds was perceived as a limiting factor in having in-depth discussions regarding patient care decisions. Thus, residents felt they had less time to ask questions or challenge consensus thinking or decisions during work rounds. Rounds are busy. For example, you have to attend morning report from 7 to 8 o’clock, you have to see the patients and pre-round, then you have to do the rounds, and after rounds at 10 o'clock you have [another] activity. Your time will not allow you to argue [with a group decision]. There were also external pressures on discharge decisions of medical teams. The pressure felt by residents to discharge patients was often attributed to a cultural norm of promoting hospital throughput, thereby conflicting with thoroughness in patient evaluations. The team wanted to discharge patients very quickly from the hospital… I think there is this concept of discharging patients. We stabilize and discharge without further investigation. Residents also perceived pressure from case managers in questions directed to the team regarding reasons for prolonged hospitalizations. Also, the case manager in the group asking, ‘Why is this patient in the hospital for so long?’ or ‘What's the indication [for continued hospitalization]?’ contributes to the push for discharging patients. Theme 3: Post-call challenges in decision making. Residents reported several aspects of post-call days that posed challenges to optimal group decision making. First, post-call days have the highest patient volume due to the number of admissions during call days. One resident recalled a case in which there was a delayed diagnosis of cellulitis due to a suboptimal evaluation of the patient during a busy post-call day with a high patient volume. It was our post-call day, which is usually very busy. We have to see lots of patients. I think this might have contributed to us not taking a good history from the patient and not examining her very well. Increased workload, which is related to patient volume, was another aspect of post-call days as it pertained to the high number of tasks that need to be executed and may put the team at risk of missing or delaying recognition of a critical finding. When there is higher workload and no one, not even the senior resident, on our team may be able to catch [everything]. We will be overwhelmed with doing the basic [things] that we need to do. As a result of higher patient volumes and workload during post-call days, residents identified fatigue as a notable influence on impaired group decision making. You cannot sleep [during call], and thus, you're not focused in a hangover state. Theme 4: Interactions between teamwork and decision making. Several aspects of teamwork were described as having an influence on the quality of group decisions in patient care. Residents identified a relationship between effective team communication and quality in group decision making. What I believe is really affecting good [decisions] for the patient is doing multiple recaps within the team, always keeping each other updated...If there is miscommunication and no proper updating about the patient, we really cause team malfunction and poor decisions. Another aspect of teamwork that was important for residents’ motivation to engage in group decision making was the degree to which team members valued each other and their motivation to work together (i.e., team cohesion). The interpersonal relationships between the healthcare workers are really essential for motivating the residents to do their best… If you're [in a group] with members who are rude and don't allow you to learn, then you will not feel as motivated to contribute. Finally, residents who felt better supported by their team members were more engaged in the group decision making process. I have worked in teams that support you and even the registrar will be very involved in the [group’s decision]. But sometimes it will be opposite. Theme 5: Personal and cultural influences in group decision making. Residents viewed personality characteristics of team members as determinants for engaging in group decision making. For the resident team member, their tendency towards being extroverted versus introverted was identified as being informative of how engaged they would be in discussions around group decisions. The personality of the consultant was also viewed as important. I once had this very nice group dynamic that was very dependent on the consultant’s personality. He was very nice and let us all [contribute to] discussions on the patient. Because everyone was involved, we could finalize a good decision. Most residents cited their inexperience or lack of confidence as barriers to speaking up in group decisions driven by more experienced clinicians. As a resident, you think that you don't have any enough experience and knowledge to argue with the consultant or the senior resident, so sometimes you don't have anything to add [to the group decision making]. Finally, residents identified cultural background as a factor in team dynamics and group decision. In this diverse residency program, consultants and trainees come from both Eastern and Western cultures. Residents attributed some of group bias and nature of group interactions to the diversity of consultants. "Sometimes maybe bias can happen [because] we have different nationalities. For example, there are some consultants [who] are demanding. They want you to be 100% perfect. Maybe this can contribute to the team harmony." Discussion This study aimed to explore medical resident’s experiences and perspectives regarding group decision making in patient care, including views on the relevance of certain group biases drawn from other fields in medical decision making. Findings in this study provide unique insights into the complexities of group decision making processes in teaching hospitals, which is an underdeveloped area of investigation within medical education. The findings reveal several key points that reflect the challenges that residents face regarding team dynamics and group decision making. Perhaps unsurprisingly, one of the primary findings is the negative influence of hierarchical structures within medical teams on group decision making. This certainly adds to well-established concerns regarding team hierarchy as a threat to patient safety.( 27 – 29 ) In this study, medical residents often perceived decision making as a top-down process starting with consultants. While some residents reported experiences with consultants who created an environment for open discussions, they often felt their contributions were undervalued based on their rank alone. Residents also identified personal and cultural influences on group decision making. For example, residents often viewed their inexperience or lack of confidence as barriers to their participation in group decision making. Culture was also a prominent factor in the nature of interactions between consultants and trainees. Hierarchical structures and power distances between teachers and learners are greater in Eastern cultures than Western cultures.( 30 ) Being in an Eastern culture such as Qatar, many residents alluded to decision making in medical teams as consultant-centered. This might also explain why nurses, social workers, or other non-physician health professionals were never mentioned as contributors to group decision making. Eastern cultures also tend to have exhibit uncertainty avoidance ( 31 ), which was identified by one resident as an expectation of certain consultants for residents to be “perfect.” This study also identified various factors that contribute to impaired group decision making experienced by medical residents. Such factors included time pressures imposed on work rounds, external pressures from other staff members, and factors specifically associated with post-call days such as high patient volume, increased workload, and fatigue. Very few studies have examined contributing factors or external forces that negatively influence medical team decision making. Lauffenburger et al. studied the influence of factors contributing to suboptimal prescribing decisions by medical residents on night shifts.( 32 ) They also discovered that time pressures and perceived pressure from other staff contributed to suboptimal decisions by medical residents. Another important finding in our study was that medical residents were able to identify group biases in past experiences to a varying extent. Most residents were able to recognize groupthink in their past experiences with group decision making; however, most had difficulty recognizing social loafing and escalation of commitment. We posit there are several underlying reasons for this. First, residents may lack sufficient education on training on decision making sciences and cognitive biases that could equip them with knowledge and skills to be able to detect them in everyday practice. Second, as several residents pointed out, some group biases may be less applicable in medical decision making compared to other domains. This calls for future research that identifies the kinds of group biases that may emerge within varying contexts and settings. This study has several limitations. The findings are based on the experiences and perspectives of medical residents from a single medical institution, which may limit the transferability of findings to other settings. In addition, asking residents to speak on past experiences may introduce recall bias or social desirability bias (answering in a manner that would be viewed favorably by others). Finally, de-identification of transcripts to preserve participants’ privacy and confidentiality limited any analysis of certain individual characteristics (such as race, ethnicity, nationality, or gender) and their role in group decision making. Future research should focus on exploring team dynamics in group decision making across diverse settings. In conclusion, this study sheds light on the nuanced and complex nature of group decision making in medical training environments. It highlights the need for future studies to enhance our understanding of group biases in medical decision making. In turn, targeted interventions that mitigate group biases and improve group decision making processes can be developed and ultimately lead to better patient care and education. Declarations Ethics approval and consent to participate. The study was approved by the Weill Cornell Medicine-Qatar and Hamad Medical Corporation Institutional Review Boards (WCM-Q IRB 22-00001 and the HMC reliance acknowledgement MRC-01022045). Consents were taken from all participants as the protocol. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding: This study was funded by a Medical Education Research grant from the Department of Medical Education at WCM-Q. Authors' contributions JJC and NM contributed to the conceptualization of the study. All authors (JJC, NM, DA, MAM) contributed to the design of this study. MAM collected data through semi-structured interviews. JJC and MAM analyzed and interpreted the data. JJC wrote the initial draft of the manuscript. 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Med Educ. 2022;56(10):1032–41. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 26 Apr, 2024 Reviews received at journal 20 Apr, 2024 Reviews received at journal 18 Apr, 2024 Reviewers agreed at journal 11 Apr, 2024 Reviewers agreed at journal 11 Apr, 2024 Reviewers invited by journal 10 Apr, 2024 Editor assigned by journal 10 Apr, 2024 Editor invited by journal 01 Apr, 2024 Submission checks completed at journal 01 Apr, 2024 First submitted to journal 07 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Choi","email":"","orcid":"","institution":"Weill Cornell Medicine","correspondingAuthor":false,"prefix":"","firstName":"Justin","middleName":"J.","lastName":"Choi","suffix":""},{"id":286999981,"identity":"f245348f-9ede-40c8-92e3-be6a44958db4","order_by":1,"name":"Nada Mhaimeed","email":"","orcid":"","institution":"Weill Cornell Medicine","correspondingAuthor":false,"prefix":"","firstName":"Nada","middleName":"","lastName":"Mhaimeed","suffix":""},{"id":286999982,"identity":"d95628f9-1fc8-4f27-af57-59ff747b1747","order_by":2,"name":"Dabia Al-Mohanadi","email":"","orcid":"","institution":"Hamad Medical Corporation","correspondingAuthor":false,"prefix":"","firstName":"Dabia","middleName":"","lastName":"Al-Mohanadi","suffix":""},{"id":286999983,"identity":"d2842088-a8fe-4d5e-9c79-a22166c34848","order_by":3,"name":"Mai A. Mahmoud","email":"data:image/png;base64,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","orcid":"","institution":"Weill Cornell Medicine","correspondingAuthor":true,"prefix":"","firstName":"Mai","middleName":"A.","lastName":"Mahmoud","suffix":""}],"badges":[],"createdAt":"2024-03-07 14:33:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4025933/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4025933/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54079246,"identity":"34cb9a40-b872-4220-8862-f22b67d4971e","added_by":"auto","created_at":"2024-04-04 09:28:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":314136,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4025933/v1/23b15c8f-3770-4b44-a80b-cbbd77c24841.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Medical residents’ experiences with group biases in medical decision making: a qualitative study","fulltext":[{"header":"Background","content":"\u003cp\u003eMedical decision making is an essential component of healthcare and training. It is a complex and dynamic process that is influenced by a wide array of clinical factors (e.g., clinical presentation, disease probabilities, test characteristics, assessment of benefits and harms) and non-clinical factors (e.g., patient preferences and values, characteristics of the clinician and practice setting).(\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) An important consideration is that many medical decision making in diagnosis and treatment processes involve the collaboration of multiple individuals\u0026mdash;broadly called group decision making.(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) This is especially critical for training skills in medical decision making, which inherently occurs within groups or teams (terms we use interchangeably in this context). This ranges from one-on-one interactions between a trainee and a preceptor to the multifaceted dynamics of a medical team. Yet, the study of group decision making in medical training is relatively underdeveloped.\u003c/p\u003e \u003cp\u003eA common perception of group decision making is that it leads to better decisions by drawing from multiple perspectives, experiences, and areas of expertise. This \"wisdom of crowds\" has been conceptualized as the collective intelligence that arises when imperfect judgments are aggregated.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) In medical decision making, collective intelligence has been demonstrated to improve diagnostic accuracy and reduce diagnostic errors by pooling or aggregating multiple physicians\u0026rsquo; judgments.(\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) However, collective intelligence in diagnosis has typically pooled independent judgments without considering the effects of group interactions (or group dynamics).\u003c/p\u003e \u003cp\u003eCertain group dynamics may hinder effective decision making, and some argue that this threatens all group decision making processes.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) Group biases (or group decision making biases) have been described as systematic patterns of deviation from rational judgment and decision making affecting groups that result in poor decisions.(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) For example, brainstorming in groups may lead to fewer ideas and less productivity (\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), which might occur due to a group bias known as \u0026lsquo;social loafing\u0026rsquo; (when some team members give less effort to problem solving in a group setting).(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) It is unknown how impaired group decision making in patient care may affect medical trainees and whether certain group biases play an important role.\u003c/p\u003e \u003cp\u003eThus, this interview study aimed to explore medical residents\u0026rsquo; experiences and perspectives regarding impaired group decision making and the role of group biases in medical decision making. We focus on medical residents because they are uniquely positioned on the \u0026lsquo;frontline\u0026rsquo; of decision making processes in teaching hospitals. They work closely with senior doctors or consultants, other health professionals, and patients, and exclusively make decisions in group settings, under supervision and/or in collaboration with others. We formulated the following research questions: What are the lived experiences of medical residents with group decisions that were suboptimal in patients\u0026rsquo; care? What are medical residents\u0026rsquo; perspectives on group biases in the context of medical decision making? Insights from this study may inform future studies and interventions that improve group decision making processes for patient care and training.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis study used a qualitative approach with thematic analysis underpinned by a social constructionist epistemology, which views knowledge (what we understand and know about the world) as co-created through social processes and focuses on how social interactions shape our understanding of the world.(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) Individual semi-structured interviews were conducted to facilitate deeper discussion of complex questions and allow participants to share detailed accounts of experiences, interpretations, and perspectives.(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) This study was conducted at Weill Cornell Medicine-Qatar (WCM-Q) and the affiliated Hamad Medical Corporation (HMC). The study was approved by the WCM-Q and HMC Institutional Review Boards (Weill Cornell Medicine-Qatar IRB 22\u0026thinsp;\u0026minus;\u0026thinsp;00001 and the Hamad Medical Corporation reliance acknowledgement MRC-01022045).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eInternal medicine residents at HMC were recruited by e-mail and provided information outlining study details. Enrolled participants were those who voluntarily responded, completed the consent process as per the protocol, and provided signed informed consent. HMC is the main healthcare provider in the state of Qatar, comprising of 12 hospitals that provide all levels of care. HMC is the main affiliate to WCM-Q, the first medical school established in Qatar where many HMC consultants have affiliate faculty appointments. HMC hospitals serve as the main teaching hospitals in Qatar that offer graduate medical education. Clinicians and trainees at HMC represent a diversity of national backgrounds from the Middle East, North Africa, Asia, Europe, and North America. In this study, a total of 16 medical residents were enrolled and then interviewed, including 5 first-year, 5 second-year, and 6 third-year residents. 8 were females.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eIn-depth, semi-structured interviews in English were conducted over 5 months, from February 24 to June 6, 2023. Interviews were conducted by MAM via video conferencing due to the COVID-19 restrictions. Each interview lasted approximately 30 to 45 minutes. Audio recordings of all interviews were transcribed and transferred to a qualitative data analysis software (Quirkos, version 2.5.3). We developed an interview guide based on a literature review and research team expertise. A general question was initially posed during the interview regarding medical residents\u0026rsquo; experiences with suboptimal medical decision making as a group or team. Then, questions targeted to several group biases were asked after providing a definition of each (see more details in the next section). As interviews progressed, in-depth questions were also posed, such as \u0026ldquo;Can you explain in more detail?\u0026rdquo;, \u0026ldquo;What were the dynamics in the group that contributed to [that]?\u0026rdquo;, and \u0026ldquo;Are there approaches that might avoid [that]?\u0026rdquo;. At the end of every interview, residents were asked \u0026ldquo;What else do you think is critical for us to know about group decision making in medicine that we have not covered?\u0026rdquo;. The data collection ended when saturation of themes was reached. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eGroup biases\u003c/h2\u003e \u003cp\u003eTo ask medical residents about their perspectives and experiences with group biases, we used a framework and definitions provided by Mannion and Thompson of three group biases drawn from social and organizational psychological studies that are relevant to patient safety and medical decision making: \u0026lsquo;groupthink\u0026rsquo;, \u0026lsquo;social loafing\u0026rsquo;, and \u0026lsquo;escalation of commitment\u0026rsquo;.(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) We did not include a fourth group bias known as \u0026lsquo;group polarization\u0026rsquo; given similarities in its roots and antecedents with groupthink, and to ensure an in-depth interview could be completed within a reasonable time period.\u003c/p\u003e \u003cp\u003eGroupthink is a bias that occurs when highly cohesive groups with strongly connected members inhibit the expression of individual opinions. In such cases, group harmony may take precedence over effective decision making. Group members desire for harmony or conformity and override their motivation realistically to propose alternative courses of action. An example provided by Mannion and Thompson is when staff members agree with an idea proposed by a senior doctor, who is viewed as a charismatic leader with a national and international reputation for research, despite uncertain evidence for or against the idea, and little time is given to scrutinizing the idea.\u003c/p\u003e \u003cp\u003eSocial loafing is the phenomenon of a group member giving less effort or reducing motivation to achieve a goal when working in a group than when working alone. An example provided by Mannion and Thompson is when a multi-ward clinical audit of nursing records finds that one ward has failed to collect audit data due to the senior nurse\u0026rsquo;s assumption that her three deputies would complete the audit.\u003c/p\u003e \u003cp\u003eEscalation of commitment refers to the tendency for individuals or groups to continue to support a course of action despite evidence that it is failing. Mannion and Thompson provide an example in terms of committing further resources to a failing investment in a new information technology infrastructure. An example more directly related to medical decision making might be continuing a therapy despite a patient\u0026rsquo;s clinical deterioration rather than considering alternative treatment options or re-considering alternative diagnoses.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThematic analysis of the dataset was conducted by two researchers (JJC, MAM) within Quirkos software.(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Before coding, both researchers read all interview transcripts in an effort to familiarize themselves with the data. Then, codes were independently assigned to relevant data segments (words, phrases, sentences) in the first five transcripts. Afterwards, they met to incorporate codes and discuss discrepancies in developing a preliminary coding framework. The researchers used the coding framework on additional transcripts, added new codes as they were identified, and met several times to reach consensus on suggested codes and how these were assigned to data. After ten transcripts, no new codes emerged and a full coding framework was used to code all interviews (including previously coded transcripts). JJC reviewed all codes to search for categories of codes, identify patterns, and search for relationships with the original research questions. In doing so, JJC generated an initial set of themes. MAM read all transcripts, codes, and proposed themes to triangulate and establish agreement. In the final phase, themes were shared and discussed with all authors to prepare a report of the study findings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eReflexivity: role of researchers\u003c/h2\u003e \u003cp\u003eJJC, DA, and MAM are medical educators and researchers at WCM-Q (DA and MAM) and its home WCM campus in New York City (JJC). JJC has no role with medical residents at HMC. DA and MAM have medical education leadership roles at WCM-Q and HMC; DA primarily interfaces with medical residents as a program director, and MAM primarily interfaces with medical students as a clerkship core faculty. During the conduct of this study, NM was a medical student at WCM-Q.\u003c/p\u003e \u003cp\u003eNM and DA were not involved in data collection or data analysis, and instead, engaged in member checking by reviewing themes (from the perspectives of both a trainee and supervisor) to enhance the accuracy and credibility of the research findings. MAM conducted all interviews and maintained an awareness that her role might impact residents\u0026rsquo; willingness to share experiences. Throughout their analysis of the dataset, JJC and MAM maintained awareness of potential bias and actively sought evidence of contrary views through reflection and discussion during regular researcher meetings.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eSixteen interviews with medical residents revealed insights on suboptimal group decision making within patient care drawn from their lived experiences working in teams. Medical residents recalled instances of suboptimal group decisions for four domains of medical decision making: (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e) diagnosis (diagnostic errors); (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e) treatment (treatment errors); (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e) discharge (premature discharge); (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e) monitoring (delayed recognition of clinical deterioration). The influence of the consultant (i.e., attending physician) on the medical team played a ubiquitous role in suboptimal group decision making. Other team members that were mentioned as part of the group decision making process in these cases were other residents on the team, consulting physicians from other specialties, and in some cases, the case manager or social worker (as part of the discharge process) and the patient or family members themselves (as part of shared decision making). Notably, nurses were not mentioned by any resident in their recall of past experiences with suboptimal group decision making.\u003c/p\u003e\n\u003cp\u003eThere were mixed findings in medical residents\u0026rsquo; ability to recognize various group biases in medical decision making. Groupthink was the most readily identified by residents. In all cases of groupthink, residents found themselves following the decision or opinion of the consultant. Only two residents had difficulty recalling an experience representative of groupthink.\u003c/p\u003e\n\u003cp\u003eFor social loafing and escalation of commitment biases, few residents could identify these in their experience with patient care teams (three and five residents, respectively). Several residents viewed these group biases as not plausible in medical decision making given individual motivations and team awareness of promoting quality and safety in patient care. Some residents suggested that decreased participation during team rounds might be misconstrued as social loafing, when in fact it reflects varying roles and responsibilities (e.g., early learners leaning on the experience and expertise of senior team members) or a division of labor (individual work versus tasks requiring collaboration). Anecdotes in which social loafing was identified included a resident\u0026rsquo;s lack of interest in a specific rotation, senior residents \u0026lsquo;sitting back\u0026rsquo; at the end of the year, and a consultant with an extremely \u0026lsquo;hands off\u0026rsquo; approach with residents.\u003c/p\u003e\n\u003cp\u003eFor most cases in which escalation of commitment was perceived as a contributor to suboptimal group decisions, faulty diagnostic reasoning (e.g, not questioning the accepted diagnosis, failure to consider other possible diagnoses) played a prominent role. For example, a medical team continued pursuing a diagnosis (e.g., tuberculosis workup) and failed to change an accepted diagnosis (e.g., heart failure exacerbation) despite repeated negative testing and worsening of the patient\u0026rsquo;s condition, respectively. For one resident, escalation of commitment was most noticeable in management plans, sticking with a treatment plan or protocol despite lack of efficacy.\u003c/p\u003e\n\u003cp\u003eIn addressing medical residents\u0026rsquo; perspectives on group biases in medical decision making, 5 themes with subthemes were identified (Table). We present and discuss these below with representative quotes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable.\u003c/strong\u003e Major themes and subthemes summarizing medical residents\u0026rsquo; experiences with and perspectives on group biases in medical decision making.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 1: Hierarchical influence on group decision making\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSubthemes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eTop-down decision making\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eConformity vs autonomy\u003c/li\u003e\n \u003cli\u003ePerceived value in judgments and decisions\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 2: Group decision making under pressure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSubthemes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eTime pressures during work rounds\u003c/li\u003e\n \u003cli\u003ePressure to discharge patients\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 3: Post-call challenges in decision making\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSubthemes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eHigh patient volume\u003c/li\u003e\n \u003cli\u003eIncreased workload\u003c/li\u003e\n \u003cli\u003eFatigue in decision making\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 4: Interactions between teamwork and decision making\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSubthemes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eCommunication\u003c/li\u003e\n \u003cli\u003eCohesion\u003c/li\u003e\n \u003cli\u003eMutual support\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 5: Personal and cultural influences in group decision making\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSubthemes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eIndividual personalities\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePersonal experience and confidence\u003c/li\u003e\n \u003cli\u003eCultural influences\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eTheme 1: Hierarchical influence on group decision making.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMost residents viewed group decision making in patient care as a top-down process that starts with the consultant. Residents felt there are few opportunities challenge the consultant on decisions they have made, thus withholding their opinions or questions on any given decision.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eThe decision is made by the most senior member of the team, so we cannot do much about it.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eDue to the hierarchy in medical decision making, residents perceived a tension between conforming to the group decision and expressing individual thoughts.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e[Sometimes] you just go with the flow and you try not to disrupt the group with an individual thought.\u003c/p\u003e\n \u003cp\u003eYou just go with the flow and do what you\u0026apos;re supposed to do. You\u0026apos;re not even allowed to question [the consultant\u0026rsquo;s decision]. Because everyone does this, and for your peace of mind, you don\u0026apos;t argue a lot.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eMost residents felt that a lower rank in the medical team hierarchy was associated with lower value placed by more senior team members on their judgments and decisions. On the other hand, other residents reported that some consultants did value the input of the lowest ranking team members.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eBecause of your title as a \u0026lsquo;PGY-1\u0026rsquo;, no one takes your ideas seriously\u0026hellip;Hierarchy is the main problem.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003eTheme 2: Group decision making under pressure.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eResidents described several external pressures that influenced both the group decision making process and final decisions made as a group. For example, time constraints on work rounds was perceived as a limiting factor in having in-depth discussions regarding patient care decisions. Thus, residents felt they had less time to ask questions or challenge consensus thinking or decisions during work rounds.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eRounds are busy. For example, you have to attend morning report from 7 to 8 o\u0026rsquo;clock, you have to see the patients and pre-round, then you have to do the rounds, and after rounds at 10 o\u0026apos;clock you have [another] activity. Your time will not allow you to argue [with a group decision].\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eThere were also external pressures on discharge decisions of medical teams. The pressure felt by residents to discharge patients was often attributed to a cultural norm of promoting hospital throughput, thereby conflicting with thoroughness in patient evaluations.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eThe team wanted to discharge patients very quickly from the hospital\u0026hellip; I think there is this concept of discharging patients. We stabilize and discharge without further investigation.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eResidents also perceived pressure from case managers in questions directed to the team regarding reasons for prolonged hospitalizations.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eAlso, the case manager in the group asking, \u0026lsquo;Why is this patient in the hospital for so long?\u0026rsquo; or \u0026lsquo;What\u0026apos;s the indication [for continued hospitalization]?\u0026rsquo; contributes to the push for discharging patients.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003eTheme 3: Post-call challenges in decision making.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eResidents reported several aspects of post-call days that posed challenges to optimal group decision making. First, post-call days have the highest patient volume due to the number of admissions during call days. One resident recalled a case in which there was a delayed diagnosis of cellulitis due to a suboptimal evaluation of the patient during a busy post-call day with a high patient volume.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eIt was our post-call day, which is usually very busy. We have to see lots of patients. I think this might have contributed to us not taking a good history from the patient and not examining her very well.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eIncreased workload, which is related to patient volume, was another aspect of post-call days as it pertained to the high number of tasks that need to be executed and may put the team at risk of missing or delaying recognition of a critical finding.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eWhen there is higher workload and no one, not even the senior resident, on our team may be able to catch [everything]. We will be overwhelmed with doing the basic [things] that we need to do.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eAs a result of higher patient volumes and workload during post-call days, residents identified fatigue as a notable influence on impaired group decision making.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eYou cannot sleep [during call], and thus, you\u0026apos;re not focused in a hangover state.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003eTheme 4: Interactions between teamwork and decision making.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSeveral aspects of teamwork were described as having an influence on the quality of group decisions in patient care. Residents identified a relationship between effective team communication and quality in group decision making.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eWhat I believe is really affecting good [decisions] for the patient is doing multiple recaps within the team, always keeping each other updated...If there is miscommunication and no proper updating about the patient, we really cause team malfunction and poor decisions.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eAnother aspect of teamwork that was important for residents\u0026rsquo; motivation to engage in group decision making was the degree to which team members valued each other and their motivation to work together (i.e., team cohesion).\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eThe interpersonal relationships between the healthcare workers are really essential for motivating the residents to do their best\u0026hellip; If you\u0026apos;re [in a group] with members who are rude and don\u0026apos;t allow you to learn, then you will not feel as motivated to contribute.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eFinally, residents who felt better supported by their team members were more engaged in the group decision making process.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eI have worked in teams that support you and even the registrar will be very involved in the [group\u0026rsquo;s decision]. But sometimes it will be opposite.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003eTheme 5: Personal and cultural influences in group decision making.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eResidents viewed personality characteristics of team members as determinants for engaging in group decision making. For the resident team member, their tendency towards being extroverted versus introverted was identified as being informative of how engaged they would be in discussions around group decisions. The personality of the consultant was also viewed as important.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eI once had this very nice group dynamic that was very dependent on the consultant\u0026rsquo;s personality. He was very nice and let us all [contribute to] discussions on the patient. Because everyone was involved, we could finalize a good decision.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eMost residents cited their inexperience or lack of confidence as barriers to speaking up in group decisions driven by more experienced clinicians.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eAs a resident, you think that you don\u0026apos;t have any enough experience and knowledge to argue with the consultant or the senior resident, so sometimes you don\u0026apos;t have anything to add [to the group decision making].\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eFinally, residents identified cultural background as a factor in team dynamics and group decision. In this diverse residency program, consultants and trainees come from both Eastern and Western cultures. Residents attributed some of group bias and nature of group interactions to the diversity of consultants.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Sometimes maybe bias can happen [because] we have different nationalities. For example, there are some consultants [who] are demanding. They want you to be 100% perfect. Maybe this can contribute to the team harmony.\u0026quot;\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to explore medical resident\u0026rsquo;s experiences and perspectives regarding group decision making in patient care, including views on the relevance of certain group biases drawn from other fields in medical decision making. Findings in this study provide unique insights into the complexities of group decision making processes in teaching hospitals, which is an underdeveloped area of investigation within medical education. The findings reveal several key points that reflect the challenges that residents face regarding team dynamics and group decision making.\u003c/p\u003e\n\u003cp\u003ePerhaps unsurprisingly, one of the primary findings is the negative influence of hierarchical structures within medical teams on group decision making. This certainly adds to well-established concerns regarding team hierarchy as a threat to patient safety.(\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e) In this study, medical residents often perceived decision making as a top-down process starting with consultants. While some residents reported experiences with consultants who created an environment for open discussions, they often felt their contributions were undervalued based on their rank alone.\u003c/p\u003e\n\u003cp\u003eResidents also identified personal and cultural influences on group decision making. For example, residents often viewed their inexperience or lack of confidence as barriers to their participation in group decision making. Culture was also a prominent factor in the nature of interactions between consultants and trainees. Hierarchical structures and power distances between teachers and learners are greater in Eastern cultures than Western cultures.(\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e) Being in an Eastern culture such as Qatar, many residents alluded to decision making in medical teams as consultant-centered. This might also explain why nurses, social workers, or other non-physician health professionals were never mentioned as contributors to group decision making. Eastern cultures also tend to have exhibit uncertainty avoidance (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e), which was identified by one resident as an expectation of certain consultants for residents to be \u0026ldquo;perfect.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eThis study also identified various factors that contribute to impaired group decision making experienced by medical residents. Such factors included time pressures imposed on work rounds, external pressures from other staff members, and factors specifically associated with post-call days such as high patient volume, increased workload, and fatigue. Very few studies have examined contributing factors or external forces that negatively influence medical team decision making. Lauffenburger et al. studied the influence of factors contributing to suboptimal prescribing decisions by medical residents on night shifts.(\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e) They also discovered that time pressures and perceived pressure from other staff contributed to suboptimal decisions by medical residents.\u003c/p\u003e\n\u003cp\u003eAnother important finding in our study was that medical residents were able to identify group biases in past experiences to a varying extent. Most residents were able to recognize groupthink in their past experiences with group decision making; however, most had difficulty recognizing social loafing and escalation of commitment. We posit there are several underlying reasons for this. First, residents may lack sufficient education on training on decision making sciences and cognitive biases that could equip them with knowledge and skills to be able to detect them in everyday practice. Second, as several residents pointed out, some group biases may be less applicable in medical decision making compared to other domains. This calls for future research that identifies the kinds of group biases that may emerge within varying contexts and settings.\u003c/p\u003e\n\u003cp\u003eThis study has several limitations. The findings are based on the experiences and perspectives of medical residents from a single medical institution, which may limit the transferability of findings to other settings. In addition, asking residents to speak on past experiences may introduce recall bias or social desirability bias (answering in a manner that would be viewed favorably by others). Finally, de-identification of transcripts to preserve participants\u0026rsquo; privacy and confidentiality limited any analysis of certain individual characteristics (such as race, ethnicity, nationality, or gender) and their role in group decision making. Future research should focus on exploring team dynamics in group decision making across diverse settings.\u003c/p\u003e\n\u003cp\u003eIn conclusion, this study sheds light on the nuanced and complex nature of group decision making in medical training environments. It highlights the need for future studies to enhance our understanding of group biases in medical decision making. In turn, targeted interventions that mitigate group biases and improve group decision making processes can be developed and ultimately lead to better patient care and education.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate.\u0026nbsp;\u003c/strong\u003eThe study was approved by the Weill Cornell Medicine-Qatar and Hamad Medical Corporation Institutional\u003cem\u003e\u0026nbsp;\u003c/em\u003eReview Boards (WCM-Q IRB 22-00001 and the HMC reliance acknowledgement\u0026nbsp;MRC-01022045). Consents were taken from all participants as the protocol.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis study was funded by a Medical Education Research grant from the Department of Medical Education at WCM-Q.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJJC and NM contributed to the conceptualization of the study. All authors (JJC, NM, DA, MAM) contributed to the design of this study. MAM collected data through semi-structured interviews. JJC and MAM analyzed and interpreted the data. JJC wrote the initial draft of the manuscript. All authors were major contributors in reading, editing, and revising the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMcNeil BJ, Keller E, Adelstein SJ. Primer on certain elements of medical decision making. N Engl J Med. 1975;293(5):211\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePauker SG, Kassirer JP. Therapeutic decision making: a cost-benefit analysis. N Engl J Med. 1975;293(5):229\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcKinlay JB, Potter DA, Feldman HA. Non-medical influences on medical decision-making. Soc Sci Med. 1996;42(5):769\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHajjaj FM, Salek MS, Basra MKA, Finlay AY. Non-clinical influences on clinical decision-making: a major challenge to evidence-based practice. J R Soc Med. 2010;103(5):178\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith M, Higgs J, Ellis E. Factors influencing clinical decision making. Clin reasoning health professions. 2008;3:89\u0026ndash;100.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCommittee on Diagnostic Error in Health Care, Board on Health Care Services, Institute of Medicine. In: Miller BT, Ball JR, editors. The National Academies of Sciences, Engineering, and Medicine. Improving diagnosis in health care. Balogh EP. Washington (DC): National Academies Press (US); 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThe wisdom of crowds. Why the many are smarter than the few and how collective wisdom shapes business, economies, societies, and nations. [Internet]. [cited 2024 Jan 27]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://psycnet.apa.org/record/2004-20179-000\u003c/span\u003e\u003cspan address=\"https://psycnet.apa.org/record/2004-20179-000\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKurvers RHJM, Herzog SM, Hertwig R, Krause J, Carney PA, Bogart A, et al. Boosting medical diagnostics by pooling independent judgments. Proc Natl Acad Sci USA. 2016;113(31):8777\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarnett ML, Boddupalli D, Nundy S, Bates DW. Comparative accuracy of diagnosis by collective intelligence of multiple physicians vs individual physicians. JAMA Netw Open. 2019;2(3):e190096.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKurvers RHJM, Nuzzolese AG, Russo A, Barabucci G, Herzog SM, Trianni V. Automating hybrid collective intelligence in open-ended medical diagnostics. Proc Natl Acad Sci USA. 2023;120(34):e2221473120.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStehouwer NR, Torrey KW, Dell MS. Collective intelligence improves probabilistic diagnostic assessments. Diagnosis (Berl). 2023;10(2):158\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAldag RJ, Fuller SR. Beyond fiasco: A reappraisal of the groupthink phenomenon and a new model of group decision processes. Psychol Bull. 1993;113(3):533\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaron RS. So right it\u0026rsquo;s wrong: groupthink and the ubiquitous nature of polarized group decision making. Elsevier; 2005. pp. 219\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJones PE, Roelofsma PH. The potential for social contextual and group biases in team decision-making: biases, conditions and psychological mechanisms. Ergonomics. 2000;43(8):1129\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDunnette MD, Campbell J, Jaastad K. The effect of group participation on brainstorming effectiveness for 2 industrial samples. J Appl Psychol. 1963;47(1):30\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLamm H, Trommsdorff G. Group versus individual performance on tasks requiring ideational proficiency (brainstorming): A review. Eur J Soc Psychol. 1973;3(4):361\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiehl M, Stroebe W. Productivity loss in brainstorming groups: Toward the solution of a riddle. J Pers Soc Psychol. 1987;53(3):497\u0026ndash;509.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiehl M, Stroebe W. Productivity loss in idea-generating groups: Tracking down the blocking effect. J Pers Soc Psychol. 1991;61(3):392\u0026ndash;403.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJackson JM, Williams KD. Social loafing on difficult tasks: Working collectively can improve performance. J Pers Soc Psychol. 1985;49(4):937\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKvale S. The social construction of validity. Qualitative Inq. 1995;1(1):19\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiCicco-Bloom B, Crabtree BF. The qualitative research interview. Med Educ. 2006;40(4):314\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBowen GA. Naturalistic inquiry and the saturation concept: a research note. Qualitative Res. 2008;8(1):137\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMannion R, Thompson C. Systematic biases in group decision-making: implications for patient safety. Int J Qual Health Care. 2014;26(6):606\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorbin JM, Strauss A. Grounded theory research: Procedures, canons, and evaluative criteria. Qual Sociol. 1990;13(1):3\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStrauss A, Corbin JM. Grounded theory in practice. Sage; 1997.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSydor DT, Bould MD, Naik VN, Burjorjee J, Arzola C, Hayter M, et al. Challenging authority during a life-threatening crisis: the effect of operating theatre hierarchy. Br J Anaesth. 2013;110(3):463\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBould MD, Sutherland S, Sydor DT, Naik V, Friedman Z. Residents\u0026rsquo; reluctance to challenge negative hierarchy in the operating room: a qualitative study. Can J Anaesth. 2015;62(6):576\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVoogt JJ, Kars MC, van Rensen ELJ, Schneider MME, Noordegraaf M, van der Schaaf MF. Why medical residents do (and don\u0026rsquo;t) speak up about organizational barriers and opportunities to improve the quality of care. Acad Med. 2020;95(4):574\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChuenjitwongsa S, Bullock A, Oliver RG. Culture and its influences on dental education. Eur J Dent Educ. 2018;22(1):57\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHofstede G. Culture and Organizations. Int Stud Manage Organ. 1980;10(4):15\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLauffenburger JC, Coll MD, Kim E, Robertson T, Oran R, Haff N, et al. Prescribing decision making by medical residents on night shifts: A qualitative study. Med Educ. 2022;56(10):1032\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"bias, group decision making, groupthink, team dynamics","lastPublishedDoi":"10.21203/rs.3.rs-4025933/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4025933/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSystematic biases in group decision making (i.e., group biases) may result in suboptimal decisions and potentially harm patients. It is not well known how impaired group decision making in patient care may affect medical training. This study aimed to explore medical residents\u0026rsquo; experiences and perspectives regarding impaired group decision making and the role of group biases in medical decision making.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study used a qualitative approach with thematic analysis underpinned by a social constructionist epistemology. Semi-structured interviews of medical residents were conducted at a single internal medicine residency program. Residents were initially asked about their experiences with suboptimal medical decision making as a group or team. Then, questions were targeted to several group biases (groupthink, social loafing, escalation of commitment). Interviews were transcribed and transferred to a qualitative data analysis software. Thematic analysis was conducted to generate major themes within the dataset.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSixteen interviews with residents revealed five major themes: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) hierarchical influence on group decision making; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) group decision making under pressure; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) post-call challenges in decision making; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) interactions between teamwork and decision making; and (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) personal and cultural influences in group decision making. Subthemes were also identified for each major theme. Most residents were able to recognize groupthink in their past experiences working with medical teams. Residents perceived social loafing or escalation of commitment as less relevant for medical team decision making.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eOur findings provide unique insights into the complexities of group decision making processes in teaching hospitals. Team hierarchy significantly influenced residents\u0026rsquo; experiences with group decision making\u0026mdash;most group decisions were attributed to consultants or senior team members, while lower ranking team members contributed less and perceived fewer opportunities to engage in group decisions. Other factors such as time constraints on decision making, perceived pressures from other staff members, and challenges associated with post-call days were identified as important barriers to optimal group decision making in patient care. Future studies may build upon these findings to enhance our understanding of medical team decision making and develop strategies to improve group decisions, ultimately leading to higher quality patient care and training.\u003c/p\u003e","manuscriptTitle":"Medical residents’ experiences with group biases in medical decision making: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-04 09:20:12","doi":"10.21203/rs.3.rs-4025933/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-04-26T06:32:37+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-20T20:06:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-18T06:14:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1b59cd44-573d-4ba5-ba5c-4c233de8bbaf","date":"2024-04-11T13:41:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"98ebda6c-e48d-4b02-b7ce-d89d96656751","date":"2024-04-11T13:20:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-11T00:19:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-11T00:08:35+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-04-01T14:03:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-01T13:40:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2024-03-07T14:15:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"89575376-c566-4a27-a051-f146cbcadc6a","owner":[],"postedDate":"April 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-06-10T02:40:53+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-04 09:20:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4025933","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4025933","identity":"rs-4025933","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}