[Family reconstitution and online genealogies to analyze the sex-specific differential mortality in the historical context]

BACKGROUND

Family reconstitution and data from online genealogies, such as FamiLinx, are two potential sources for investigating mortality dynamics for the period before official lifetables became available. In this paper, we use two of them, the family reconstitution of Imhof and the FamiLinx dataset based on geni.com, to estimate dynamics in life expectancy and discuss the sex-specific differential mortality in the German Empire.

METHOD

Sex-specific lifetables are estimated for the territory of the German Empire from the individual data of the family reconstitution and the online genealogies. On the basis of these lifetables, we estimate the conditional life expectancy and derive the corresponding sex-specific differential mortality. Findings are compared with the official lifetable of the German Empire in 1871-1910. The contribution of each age group to the differential mortality is determined using the stepwise-replacement algorithm.

RESULTS

The family reconstitution overestimates conditional life expectancy less than FamiLinx after 1871, when official lifetables are available in the German Empire. However, both sources fail to capture the sex-specific mortality differentials of the official lifetables at the end of the nineteenth century and show a higher life expectancy for males instead of females. The bias in sex-specific mortality rates is particularly pronounced in the age groups 15 to 45.

DISCUSSION

Finally, we discuss possible explanations for the biased findings. Notability bias, the patriarchal approach to family trees, and maternal mortality are important mechanisms in the FamiLinx dataset. Censoring due to mobility serves as a potential reason for the bias in the family reconstitution.

Blind spots in medical education - International perspectives

BACKGROUND

All individuals and groups have blind spots that can create problems if unaddressed. The goal of this study was to examine blind spots in medical education from international perspectives.

METHODS

From December 2022 to March 2023, we distributed an electronic survey through international networks of medical students, postgraduate trainees, and medical educators. Respondents named blind spots affecting their medical education system and then rated nine blind spot domains from a study of U.S. medical education along five-point Likert-type scales (1 = much less attention needed; 5 = much more attention needed). We tested for differences between blind spot ratings by respondent groups. We also analyzed the blind spots that respondents identified to determine those not previously described and performed content analysis on open-ended responses about blind spot domains.

RESULTS

There were 356 respondents from 88 countries, including 127 (44%) educators, 80 (28%) medical students, and 33 (11%) postgraduate trainees. At least 80% of respondents rated each blind spot domain as needing 'more' or 'much more' attention; the highest was 88% for 'Patient perspectives and voices that are not heard, valued, or understood.' In analyses by gender, role in medical education, World Bank country income level, and region, a mean difference of 0.5 was seen in only five of the possible 279 statistical comparisons. Of 885 blind spots documented, new blind spot areas related to issues that crossed national boundaries (e.g. international standards) and the sufficiency of resources to support medical education. Comments about the nine blind spot domains illustrated that cultural, health system, and governmental elements influenced how blind spots are manifested across different settings.

DISCUSSION

There may be general agreement throughout the world about blind spots in medical education that deserve more attention. This could establish a basis for coordinated international effort to allocate resources and tailor interventions that advance medical education.

Seeing with greater clarity: Stakeholder ratings of blind spots in U.S. medical education

BACKGROUND

Although medical education is affected by numerous blind spots, there is limited evidence to determine which blind spots to prioritize.

METHODS

In summer 2022, we surveyed stakeholders from U.S. medical education who had identified 9 domains and 72 subdomains of blind spots. Respondents used 4-point Likert-type scales to rate the extent and magnitude of problems caused for each domain and subdomain. Respondents also provided comments for which we did content analysis.

RESULTS

A total of 23/27 (85%) stakeholders responded. The majority of respondents rated each blind spot domain as moderate-major in both extent and problems they cause. Patient perspectives and voices that are not heard, valued, or understood was the domain with the most stakeholders rating extent (n = 20, 87%) and problems caused (n = 23, 100%) as moderate or major. Admitting and selecting learners likely to practice in settings of highest need was the subdomain with the most stakeholders rating extent (n = 21, 91%) and problems caused (n = 22, 96%) as moderate or major. Respondents' comments suggested blind spots may depend on context and persist because of hierarchies and tradition.

DISCUSSION

We found blind spots differed in relative importance. These data may inform further research and direct interventions to improve medical education.

The ELSI Virtual Forum, 30 Years of the Genome: Integrating and Applying ELSI Research

This paper reports our analysis of the ELSI Virtual Forum: 30 Years of the Genome: Integrating and Applying ELSI Research, an online meeting of scholars focused on the ethical, legal, and social implications (ELSI) of genetics and genomics.

Recommendations to reduce the streetlight effect and gray areas limiting the knowledge of the effects of plant protection products on biodiversity

Preserving biodiversity against the adverse effects of plant protection products (PPPs) is a major environmental and societal issue. However, despite intensive investigation into the ecotoxicological effects of PPPs, the knowledge produced remains fragmented given the sheer diversity of PPPs. This is due, at least in part, to a strong streetlight effect in the field of ecotoxicology. Indeed, while some PPPs have been investigated in numerous ecotoxicological studies, there are many for which the scientific literature still has little or no information on their ecotoxicological risks and effects. The PPPs under the streetlight include a large variety of legacy substances and a more limited number of more recent or currently-in-use substances, such as the herbicide glyphosate and the neonicotinoid insecticides. Furthermore, many of the most recent PPPs (including those used in biocontrol) and PPP transformation products (TPs) resulting from abiotic and/or biotic degradation are rarely addressed in the international literature in the field of ecotoxicology. Here, based on a recent collective scientific assessment of the effects of PPPs on biodiversity and ecosystem services in the French and European contexts, this article sets out to illustrate the limitations and biases caused by the streetlight effect and numbers of gray areas, and issue recommendations on how to overcome them.

The less-is-better effect: a developmental perspective

The less-is-better effect emerges when an option of lesser quantitative value is preferred or overvalued relative to a quantitively greater alternative (e.g., 24-piece dinnerware set > 24-piece dinnerware set with 16 additional broken dishes; Hsee, 1998, Journal of Behavioral Decision Making, 11, 107-121). This decisional bias emerges when the option of lesser quantitative value is perceived as qualitatively better (e.g., smaller set of intact dishes > larger set of partially broken dishes). Interestingly, this effect emerges for adult humans when options are evaluated separately but dissipates when options are considered simultaneously. The less-is-better bias has been attributed to the evaluability hypothesis: individuals judge objects on the basis of easy-to-evaluate attributes when judged in isolation, such as the brokenness of items within a set, yet shift to quantitative information when evaluated jointly, such as the overall number of dishes. This bias emerges for adult humans and chimpanzees in a variety of experimental settings but has not yet been evaluated among children. In the current study, we presented a joint evaluation task (larger yet qualitatively inferior option vs. smaller yet qualitatively superior option) to children aged 3 to 9 years old to better understand the developmental trajectory of the less-is-better effect. Children demonstrated the bias across all choice trials, preferring an objectively smaller set relative to a larger yet qualitatively poorer alternative. These developmental findings suggest that young children rely upon salient features of a set to guide decision-making under joint evaluation versus more objective attributes such as quantity/value.

Differences in decisions affected by cognitive biases: examining human values, need for cognition, and numeracy

A better understanding of factors that can affect preferences and choices may contribute to more accurate decision-making. Several studies have investigated the effects of cognitive biases on decision-making and their relationship with cognitive abilities and thinking dispositions. While studies on behaviour, attitude, personality, and health worries have examined their relationship with human values, research on cognitive bias has not investigated its relationship to individual differences in human values. The purpose of this study was to explore individual differences in biased choices, examining the relationships of the human values self-direction, conformity, power, and universalism with the anchoring effect, the framing effect, the certainty effect, and the outcome bias, as well as the mediation of need for cognition and the moderation of numeracy in these relationships. We measured individual differences and within-participant effects with an online questionnaire completed by 409 Brazilian participants, with an age range from 18 to 80 years, 56.7% female, and 43.3% male. The cognitive biases studied consistently influenced choices and preferences. However, the biases showed distinct relationships with the individual differences investigated, indicating the involvement of diverse psychological mechanisms. For example, people who value more self-direction were less affected only by anchoring. Hence, people more susceptible to one bias were not similarly susceptible to another. This can help in research on how to weaken or strengthen cognitive biases and heuristics.

(A lack of) effects of acute social stress on attentional bias to threat

Attentional biases toward or away from emotionally evocative stimuli have been well documented and are known to be clinically relevant, making it important to understand how various factors contribute to them. Some work has suggested that acute stress modulates attentional biases, but this work has produced inconsistent results. For example, many studies have found that stress enhances attentional bias, others that stress decreases attentional bias, and others still that there is no effect of stress at all. Methodological differences may explain these inconsistencies. For example, discrepancies exist between studies in participant sex (e.g., mixed sample vs. all men) and in the type of attentional bias paradigm. We addressed these gaps by examining the effects of an acute social stressor (vs. control) on attentional bias assessed via facial dot probe, focusing on potential sex differences in these effects (N = 141). We found that, overall, participants were significantly biased towards threat, but biases did not differ by stress condition or sex. These findings help to clarify the existing discrepancy in the literature, as we found that stress exerts little if any effect on attentional bias assessed via a facial dot probe.

Bias analysis in forensic and non-forensic psychiatric assessments

In this research, we provide two important contributions to the psychiatric community. First, we offer the first valid and reliable cognitive test that measures forensic clinicians' ability to detect and avoid diagnostic biases in psychiatric assessments. Second, we also estimate the prevalence of clinical decision bias detection and prevention ability among psychiatrists and psychologists. A total of 1069 clinicians from different specialties (317 psychiatrists and 752 clinical psychologists, of which 286 were forensic clinicians) participated in this research. The Checklist of Biases for Clinicians (BIAS-31) was developed, and its psychometric properties were analyzed. The prevalence of bias detection and prevention was estimated using BIAS-31 scores. The BIAS-31 is valid and reliable for measuring clinicians' ability to avoid and detect clinical biases. Between 41.2% and 55.8% of clinicians try to avoid biased clinical judgments. Likewise, between 48.5% and 57.5% of clinicians were able to correctly detect the biases involved in the diagnostic assessment process. We did not expect to obtain these prevalences. Therefore, we discuss to what extent specific training in the prevention of diagnostic biases is necessary and propose several clinical strategies to prevent a priori the occurrence of biases in the psychiatric assessment.

How do they differ during medical education?

OBJECTIVE

This cross-sectional study was a first to attempt to assess how biases towards age, gender and sexual orientation differ during the years of undergraduate medical education.

METHODS

600 medical students from the first, third and sixth year of study participated in the study. Three questionnaires were used: The Ambivalent Sexism Inventory scale (ASI), the Fraboni Scale of Ageism (FSA) and the Homophobia scale (HSc).

RESULTS

Results showed statistical significant differences between the three groups in the total scores of ageism and homophobia. Students in the last year of studies reported more ageist and more homophobic biases than students in the first year of their studies.

CONCLUSIONS

Our results demonstrate a need for education to reduce/address/mitigate bias in medical students. Τhe finding that biases increase in students who are farther along in their education needs further investigation. This warrants particular attention to determine if this is a change due to the medical education process itself.

PRACTICE IMPLICATIONS

Medical education should teach students about diversity and acceptability with updated curriculums and designed interventions.

Why leading is (almost) as important as winning

Competitions in sports, business, or politics often provide perceivers with cumulative standings over time. Recent research suggests that people fail to accurately update their impressions from cumulative observations as they are influenced by previous standings. This cumulative redundancy bias (CRB) implies that competitors that are leading during a competition will receive more favorable evaluations, over and beyond their eventual success or failure. While the CRB has far-reaching implications, its underlying mechanisms are not fully understood. We present data from four experiments in which we modified the standard CRB task by adding a step-by-step procedure to track the dynamics of perceivers' impressions during the competition. We also manipulated the length of the competition and tested different possible explanations for the CRB. Results suggest that the CRB is a robust phenomenon that constitutes an actual bias and that is best explained by an additive effect of cumulative redundancy.

Blind spots in medical education: how can we envision new possibilities?

As human beings, we all have blind spots. Most obvious are our visual blind spots, such as where the optic nerve meets the retina and our inability to see behind us. It can be more difficult to acknowledge our other types of blind spots, like unexamined beliefs, assumptions, or biases. While each individual has blind spots, groups can share blind spots that limit change and innovation or even systematically disadvantage certain other groups. In this article, we provide a definition of blind spots in medical education, and offer examples, including unfamiliarity with the evidence and theory informing medical education, lack of evidence supporting well-accepted and influential practices, significant absences in our scholarly literature, and the failure to engage patients in curriculum development and reform. We argue that actively helping each other see blind spots may allow us to avoid pitfalls and take advantage of new opportunities for advancing medical education scholarship and practice. When we expand our collective field of vision, we can also envision more "adjacent possibilities," future states near enough to be considered but not so distant as to be unimaginable. For medical education to attend to its blind spots, there needs to be increased participation among all stakeholders and a commitment to acknowledging blind spots even when that may cause discomfort. Ultimately, the better we can see blind spots and imagine new possibilities, the more we will be able to adapt, innovate, and reform medical education to prepare and sustain a physician workforce that serves society's needs.

Is it a judgment of representativeness? Re-examining the birth sequence problem

Although all birth orders in the "birth sequence problem" are equiprobable, most participants judge the less representative order as less likely than the more representative order. But this well-known problem confounds representativeness with the direction in which birth orders are compared. We hypothesized and corroborated in three experiments (total N = 1,136) that participants pragmatically infer the birth orders' relative prevalence from the direction of comparison. Experiment 1 found that participants judged the less representative sequence as more common when we reversed the comparison. Experiment 2 reproduced these results despite removing representativeness as a cue. In Experiment 3, participants preferred to place the relatively common sequence as the referent in an inverted "speaker" problem. Our results turn the iconic problem's interpretation on its head: Rather than indicating flawed human cognition, the birth sequence problem illustrates people's ability to adaptively extract subtle linguistic meaning beyond the literal content.

Biased reporting of past self-injurious thoughts and behaviors: A literature review

BACKGROUND

Accurate assessment of suicide risk is critical for clinical practice, empirical advances, and informing public policy. In this narrative review of the literature, we compiled evidence from longitudinal studies that identify reporting bias of past self-injurious thoughts and behaviors (SITB) and examined possible correlates of inconsistent reporting.

METHOD

We conducted an extensive literature search, including 19 longitudinal samples or subsamples who reported the presence of current or past SITB at an initial but not at a subsequent assessment (yes/no inconsistent reports).

RESULTS

The median was 33%, and the weighted mean was 39% (95% CI, 37%-41%) for the prevalence of inconsistent reporting of SITB across the longitudinal samples. Importantly, inconsistent reports were linked with less internalizing psychopathology and more adaptive functioning. The type of sample recruited and assessment interval may also be relevant factors to consider.

LIMITATIONS

Variability of sample characteristics and methodology made it challenging to draw firm conclusions across studies but provide information about critical sources of bias.

CONCLUSIONS

Results suggest considerable caution for clinical, empirical, and policy decision-making based on lifetime reports of suicide and encourage a continued consideration for identifying potential reporting biases for SITB.

Alcohol - The myth of cardiovascular protection

BACKGROUND & AIMS

To investigate potential biases that exist in available epidemiological evidence resulting in negative associations or underestimation of cardiovascular (CV) risk associated with alcohol consumption.

METHODS

UK Biobank involved baseline data collection from 22 assessment centres across the United Kingdom. The cohort consisted of 333 259 alcohol consumers and 21 710 never drinkers. Participants were followed up for a median 6.9 years capturing incident fatal and non-fatal CV events, ischemic heart disease and cerebrovascular disease. Alcohol intake was reported as grams/week.

RESULTS

Using never drinkers as reference, alcohol from all drink types combined (hazard ratios ranging between 0.61 and 0.74), beer/cider (0.70-0.80) and spirits combined, and all wines combined (0.66-0.77) associated with a reduced risk for all outcome measures (all CV events, ischaemic heart disease, cerebrovascular disease). In continuous analysis, alcohol captured from all drink types combined (hazard ratio, 1.08, 95% confidence interval, 1.01-1.14), and beer/cider and spirits combined (1.24, 1.17-1.31) associated with an increased risk for overall CV events, however hazard ratios were stronger for beer/cider and spirits (P < 0.0001). Wine associated with a reduced risk for overall CV events (0.92, 0.86-0.98) and ischemic heart disease (0.75, 0.67-0.84). This negative relationship with overall CV events was lost after excluding ischemic heart disease events (1.00, 0.93-1.08), while the positive association of alcohol captured from beer/cider and spirits remained significant (1.30, 1.22-1.40). This positive association with overall CV events was present even when consuming less than 14 units per week.

CONCLUSIONS

Avoiding potential biases prevents underestimation of cardiovascular risk and indicates that consuming up to 14 units per week also associated with increased CV risk in the general population.

Prognostication in neurology

Prognosticating is central to primary palliative care in neurology. Many neurologic diseases carry a high burden of troubling symptoms, and many individuals consider health states due to neurologic disease worse than death. Many patients and families report high levels of need for information at all disease stages, including information about prognosis. There are many barriers to communicating prognosis including prognostic uncertainty, lack of training and experience, fear of destroying hope, and not enough time. Developing the right mindset, tools, and skills can improve one's ability to formulate and communicate prognosis. Prognosticating is subject to many biases which can dramatically affect the quality of patient care; it is important for providers to recognize and reduce them. Patients and surrogates often do not hear what they are told, and even when they hear correctly, they form their own opinions. With practice and self-reflection, one can improve their prognostic skills, help patients and families create honest roadmaps of the future, and deliver high-quality person-centered care.

[Main biases in clinical research]

In developing a research protocol, authors must consider the possible errors that may occur throughout the study. In clinical research, two types of biases are recognized: random errors and systematic errors; the latter are called biases. To date, dozens of biases have been described, which is why the purpose of this article is to describe the main biases that can occur in clinical research studies, as well as strategies to avoid them or to minimize their effects. Since there are several classifications, in order to provide a more practical overview in this review, the biases are grouped into three types: selection biases, information (or performance) biases, and confounding biases. In addition, to make it even more specific, we describe the biases considering the purpose of the research: prognosis, therapeutics, causality, and diagnostic test studies.

The Intersection of Behavioral Economics and the General Medicine Literature

Judgment and decision-making influence health-related behavior and clinical decision-making and, ultimately, health. It has been estimated that more than half of health disorders derive from behavioral consequences of unhealthy choices. We considered the question of how to better understand and improve decision-making in health and medicine through a narrative review of use and examples of concepts from Behavioral Economics, a field of study that combines insights from behavioral science and economic decision-making, in the 3 highest-impact general medicine journals.

SNO 2020 diversity survey: defining demographics, racial biases, career success metrics and a path forward for the field of neuro-oncology

BACKGROUND

Neuro-oncology has grown tremendously since 2010, marked by increasing society membership, specialized clinical expertise, and new journals. Yet, modest improvement in racial/ethnic diversity amongst clinical trial participants, researchers and clinicians led us to conduct a survey to identify opportunities to enhance diversity and inclusiveness amongst neuro-oncology professionals.

METHODS

In summer 2020, the Women and Diversity Committee of the Society for Neuro-Oncology (SNO) distributed an anonymous online survey to members and affiliates including European Association of Neuro-Oncology (EANO), Asian Society for Neuro-Oncology (ASNO), Society for Neuro-Oncology Latin America (SNOLA) and Society for Neuro-Oncology Sub-Saharan Africa (SNOSSA). The survey captured personal and professional characteristics, biases, effective mentorship qualities, career service metrics and suggested field/society changes. Results were analyzed by geography, profession, age, racial/ethnic and sexual identity. Standard descriptive statistics characterized the study population.

RESULTS

The 386 respondents were predominantly female (58%) with a median age range of 40-49 years (31%), White (65%), and SNO members (97%). Most worked in North America (77%) in a research profession (67%). A majority of White respondents reported never experiencing biases (64%), while the majority of non-White respondents reported unconscious biases/microaggressions, followed by a lack of/limited mentorship. Qualitative assessments showcased that personal/professional success metrics were linked to needed improvements in diversity and inclusion efforts within the neuro-oncology field.

CONCLUSIONS

The prevalence of racial/ethnic biases and poor mentorship rates amongst underrepresented groups in neuro-oncology is high and potentially linked to the limited diverse representation amongst members and affiliates. These findings warrant a swift implementation of equity and inclusion practices within the neuro-oncology field.

[Gender blindness in medical textbooks: the case of leukemias]

OBJECTIVE

To analyse the existence of sex-differences in the content on leukemias in the Haematology and Internal Medicine textbooks recommended in the Medical Degrees, 2019-2020, by comparison with the sex-differences recognized in the scientific literature.

METHOD

Manifest content analysis of the content of chapters on leukemias in the books on hematology and internal medicine, clinical haematology and haematology undergraduate. Analysis categories: epidemiology, etiopathogenesis, diagnosis, treatment and prognosis of leukemias.

RESULTS

Epidemiological information from the revised books has a greater consideration of sex differences in incidence and prognosis but does not contain data on mortality and survival. Etiopathogenesis is described in all books as the same physiological process for both sexes and no differences in the presentation of symptoms are described in any book. Three books describe a unique treatment that is assumed equal for both sexes; two books mention the treatment of acute myeloid leukemia in pregnant women and one in chronic myeloid leukemia. No book mentions sex-differences in pharmacokinetics, efficacy, or treatment toxicity, although there is greater evidence on unequal behavior between the sexes.

CONCLUSIONS

The contents of sex and gender differences in the leukemia chapters analyzed are insufficient compared to the evidence in the scientific literature today. Hematology textbooks might increase their scientific quality in future editions, including knowledge of sex-gender interaction in the sections of epidemiology, etiology, pathogenesis, diagnosis, treatment, prognosis, and consequences of leukemias, which will contribute to better professional practices, more efficient and equitable.

False polarization: Cognitive mechanisms and potential solutions

Although political polarization in the United States is real, intense, and increasing, partisans consistently overestimate its magnitude. This 'false polarization' is insidious because it reinforces actual polarization and inhibits compromise. We review empirical research on false polarization and the related phenomenon of negative meta-perceptions, and we propose three cognitive and affective processes that likely contribute to these phenomena: categorical thinking, oversimplification, and emotional amplification. Finally, we review several interventions that have shown promise in mitigating these biases.

Navigating Complex, Ethical Problems in Professional Life: a Guide to Teaching SMART Strategies for Decision-Making

This article demonstrates how instructors of professionalism and ethics training programs can integrate a professional decision-making tool in training curricula. This tool can help trainees understand how to apply professional decision-making strategies to address the threats posed by a variety of psychological and environmental factors when they are faced with complex professional and ethical situations. We begin by highlighting key decision-making frameworks and discussing factors that may undermine the use of professional decision-making strategies. Then, drawing upon findings from past research, we present the "SMART" professional decision-making framework: seeking help, managing emotions, anticipating consequences, recognizing rules and context, and testing assumptions and motives. Next, we present a vignette that poses a complex ethical and professional challenge and illustrate how each professional decision-making strategy could or should be used by characters in the case. To conclude, we review a series of educational practices and pedagogical tools intended to help trainers facilitate trainee learning, retention, and application of "SMART" decision-making strategies.

Tools to Assess the Risk of Bias and Reporting Quality of Randomized Controlled Trials in Rehabilitation

OBJECTIVES

(1) To determine whether new tools and items have been developed to evaluate the risk of bias (RoB) and reporting of randomized controlled trials (RCTs) in rehabilitation; (2) to determine which items are included in the existing reporting guidelines, and to create a matrix of items to report and conduct trials in rehabilitation as the first step for a starting a rigorous validation process.

DATA SOURCES

Searches were conducted in MEDLINE, EMBASE, and Cumulative Index to Nursing and Allied Health databases.

STUDY SELECTION

Studies should describe a newly developed tool to evaluate the RoB or quality of reporting for RCTs in the area of rehabilitation.

DATA EXTRACTION

(1) First, we extracted items from new tools identified by the electronic search strategies and then (2) we looked at the items provided by the Consolidated Standards of Reporting Trials statement and its relevant extensions. We determined whether these items were already included in our matrix of items. Items were classified based on methodological domains they accomplish, biases they were able to target, and whether they guide reporting or conduct.

DATA SYNTHESIS

Among the 1596 citations found, 23 articles were potentially relevant. From these, only 3 new scales (National Institute for Complementary Medicine Acupuncture Network, Quality of reports on spa and balneotherapy [SPAC], Assessment of Study Quality and Reporting in Exercise) were found. In addition, the newly updated Cochrane RoB tool (RoB 2.0) was included. Our matrix contained 122 unique items for any rehabilitation area, 46 items (37.7%) were related to conduct, and 58 (47.5%) were related to the reporting; 18 (14.8%) were related to both. Overall, 76 new items were added among all domains.

CONCLUSIONS

Many individual and diverse items have been used to guide the reporting and conduct of rehabilitation trials. This indicates a great variability in number of items and an apparent lack of consensus on a core set of items to be used in rehabilitation. Future research should look into developing a core set of items for the rehabilitation field.

Diversity in neurology leadership: Nuances and nudges

Underrepresented in medicine (UIM) academic physicians are poorly represented among medical school faculty when compared with their proportion in the US population, receive NIH research awards less frequently, are promoted less often, indicate lower career satisfaction, and report higher social isolation, than faculty who are not under-represented. Supporting a successful and sustainable workforce of UIM academic physicians is essential in neurology, because such neurologists are more likely to engage in research to reduce disparities in neurological outcomes that affect underserved and/or low-income communities, and help improve the paucity of diverse race-ethnic participation in clinical trials. Having more diverse academic neurologists serve in such roles could bolster their careers and model possibilities for others who share similar cultures and backgrounds. Beyond leading/joining diversity affairs committees, more UIM are needed in mainstream leadership roles. In this work, we explore self-application vs. appointment/nomination opportunities and how this play a role in leadership opportunities. In addition to considering appropriate weighing of self-applications vs. appointments based opportunities, we highlight approaches and introduce the concept of nudging. Nudging, which refers to purposely increasing the visibility and appeal of particular items with the goal of boosting the odds of selecting those items, has been shown to successfully influence the process of selection, and may help level the leadership playing field for UIM in neurology.

Quantitative and Qualitative Strategies to Strengthen Internal Validity in Randomized Trials

Although the randomized controlled trial (RCT) is the most reliable design to infer causality, evidence suggests that it is vulnerable to biases that weaken internal validity. In this paper, we review factors that introduce biases in RCTs and we propose quantitative and qualitative strategies for colleting relevant data to strengthen internal validity. The factors are related to participants' reactions to randomization, attrition, treatment perceptions, and implementation of the intervention. The way in which these factors operate is explained and pertinent empirical evidence is synthesized. Quantitative and qualitative strategies are described. Researchers can plan to assess these factors and examine their influence, providing evidence of what actually contributed to the interventions' causal impact.

Metacognitive Training for Obsessive-Compulsive Disorder: a study protocol for a randomized controlled trial

BACKGROUND

A high number of patients with obsessive-compulsive disorder (OCD) do not receive cognitive-behavioral therapy with exposure and response prevention, which is the most effective treatment for OCD. Therefore, Metacognitive Training for OCD (MCT-OCD) was developed, which is a structured group therapy aiming at the modification of dysfunctional (meta-)cognitive biases, beliefs and coping styles. It can be administered by less trained personnel, thus may reach a higher number of patients. An uncontrolled pilot study (MCT-OCD pilot version) provided first evidence that the training is highly accepted by patients; OC symptoms decreased with a high effect size (η2partial = 0.50). The aim of the present study is to address the shortcomings of the pilot study (e.g., no control group) and to assess the efficacy of the revised version of the MCT-OCD in the framework of a randomized controlled trial.

METHODS

Eighty patients with OCD will be recruited. After a blinded assessment at baseline (-t1), patients will be randomly assigned either to the intervention group (MCT-OCD; n = 40) or to a care as usual control group (n = 40). The MCT-OCD aims to enhance patients' metacognitive competence in eight modules by addressing dysfunctional (meta-)cognitive biases and beliefs associated with OCD (e.g., intolerance of uncertainty). After 8 weeks, patients will be invited to a post assessment (t1), and then they will receive a follow-up online questionnaire 3 months following t1 (t2). The primary outcome is the Y-BOCS total score, and the secondary outcomes include the HDRS, OCI-R, OBQ-44, MCQ-30, WHOQOL-BREF, BDI-II, and subjective appraisal ratings of the MCT-OCD. We expect that OC symptoms will decrease more in the intervention group compared with the care as usual control group from -t1 to t1 and that treatment gains will be maintained until t2.

DISCUSSION

The planned study is the first to investigate the MCT-OCD, a promising new treatment, in a randomized controlled trial. The MCT-OCD may help to overcome existing treatment barriers for patients with OCD.

TRIAL REGISTRATION

German Registry for Clinical Studies ( DRKS00013539 ), 22.02.2018.

Comment on epinephrine during resuscitation of traumatic cardiac arrest and increased mortality: a post hoc analysis of prospective observational study

The aim of this Letter to the Editor was to report some important biases in a recently published Article. We agreed with the notion by Yamamoto et al. that the effects of epinephrine regarding was limited without hemostasis, however, this study had major limitations such as no information on etiology of traumatic cardiac arrest (hemorrhagic or on non-hemorrhagic) and on hemostatic treatment. The results of this study should be interpreted with caution and further analysis is necessary. Finally, we commented on the necessity of future study regarding another vasopressor (ie; vasopressin) on traumatic cardiac arrest based on current evidence.

Magical Potential: Why Magic Performances Should be Used to Explore the Psychological Factors Contributing to Human Belief Formation

Beliefs in supernatural entities are integral parts of both our culturally embedded religions and more individualized magical belief systems (e.g., paranormal beliefs, spirituality). Scholars regularly link the occurrence of beliefs to individuals' cognitive and affective ways of information processing. For magical beliefs in particular, we expect children to endorse them. When reaching adulthood, however, individuals should have abandoned magical beliefs, and become pragmatic, sceptical, critical and rational thinkers. The reality is, a large proportion of the adult population can be described as magical thinkers, or report having had magical experiences, even in the recent past. Moreover, psychological research in adults shows a large range of magical beliefs, which correlate with particular psychological processing biases (e.g., repetition avoidance, seeing signal in noise). Unfortunately, these correlational studies do not tell us whether such psychological processing biases precede magical beliefs or whether they result from these magical beliefs. Knowing the direction of such relationships is key to understand which psychological biases might contribute to adult belief formation (or the persistence of beliefs from childhood). To test such causal relationships, we started to systematically apply an experimental approach in which people are exposed to anomalous events. Such a central event allows before-after comparisons of psychological biases. First empirical results confirmed that the use of magic performances, particularly when of paranormal nature, results in an important amount of paranormal explanations. Pre-existing beliefs enhanced this explanation bias. These results show how easily naïve observers can be "tricked" into unsubstantiated beliefs.

Reflection in medical education: intellectual humility, discovery, and know-how

Reflection has been proclaimed as a means to help physicians deal with medicine's inherent complexity and remedy many of the shortcomings of medical education. Yet, there is little agreement on the nature of reflection nor on how it should be taught and practiced. Emerging neuroscientific concepts suggest that human thought processes are largely nonconscious, in part inaccessible to introspection. Our knowledge of the world is fraught with uncertainty, ignorance and indeterminacy, and influenced by emotion, biases and illusions, including the illusion of not having illusions. Neuroscience also documents that lifelong learning processes may hone nonconscious cognition to high levels of sophistication, allowing rapid and precise perceptions, judgments and actions in complex situations. We argue that knowledge of mechanisms underlying human thought may be useful in designing educational programs to foster desired attributes such as curiosity, critical self-awareness and intuitive acumen in medical professionals. The juxtaposition of neuroscientific insights with ideas from Kant on reflective judgement, van Manen on tact, and Aristotle on phronésis, supports a concept of reflection that manifests as wise practice. We suggest that reflection in medical education should be (a) an imperative for educators seeking to guide learners to manage the complexity and "messiness" of medical practice, and (b) a role-modelling mode of medical practice characterized by self-correcting behaviors that culminate in good and right professional actions. An example illustrates reflective practice in the teaching and learning of physicianship.

Economic assessment of nutritional recommendations: A comment

This is a comment on the paper by Irz et al. (2015) in this journal, on nutritional recommendations. Irz et al. (2015) propose to compute the cost of a nutritional constraint as the consumer loss of surplus, derived from their observed choices. Introducing behavioral biases into an extended version of their model, I show that their proposed methodology implicitly assumes that consumer dietary choices do not involve any health considerations. The cost per quality-adjusted life year that they compute should be corrected by the size of the bias of consumers to be compared with benchmark evaluations.

De vuelta a la clínica. Métodos I. Diseños de investigación. Mayor calidad de información, mayor certeza a la respuesta

Research designs refer to the way information is obtained and are limited by ethical, economic and temporal viability. Research designs are standardized strategies to reduce biases, which in the architectural model of research are identified in the baseline state, the maneuver and the outcome; hence, there are no specific designs for each question. The design with the lowest probability of bias is the clinical trial, followed by cohort and case-control studies and, finally, by cross-sectional surveys. Among the main characteristics that give merit to research designs are the following: population inquiry, which refers to the situation of the population in relation to the clinical course/natural history of the disease; the maneuver, or action that is expected to modify the baseline state, which can be observational or experimental; follow-up, or documented monitoring that is given to each subject, which can be longitudinal or cross-sectional; and directionality, which can prolective or retrolective and refers to the timing of data collection for research purposes. It will always be better having a valuable question, even when answered with a design with higher risk of bias, than a question that is irrelevant or has no applicability.

Comparison of whole-genome bisulfite sequencing library preparation strategies identifies sources of biases affecting DNA methylation data

Background

Whole-genome bisulfite sequencing (WGBS) is becoming an increasingly accessible technique, used widely for both fundamental and disease-oriented research. Library preparation methods benefit from a variety of available kits, polymerases and bisulfite conversion protocols. Although some steps in the procedure, such as PCR amplification, are known to introduce biases, a systematic evaluation of biases in WGBS strategies is missing.

Results

We perform a comparative analysis of several commonly used pre- and post-bisulfite WGBS library preparation protocols for their performance and quality of sequencing outputs. Our results show that bisulfite conversion per se is the main trigger of pronounced sequencing biases, and PCR amplification builds on these underlying artefacts. The majority of standard library preparation methods yield a significantly biased sequence output and overestimate global methylation. Importantly, both absolute and relative methylation levels at specific genomic regions vary substantially between methods, with clear implications for DNA methylation studies.

Conclusions

We show that amplification-free library preparation is the least biased approach for WGBS. In protocols with amplification, the choice of bisulfite conversion protocol or polymerase can significantly minimize artefacts. To aid with the quality assessment of existing WGBS datasets, we have integrated a bias diagnostic tool in the Bismark package and offer several approaches for consideration during the preparation and analysis of WGBS datasets.

Electronic supplementary material

The online version of this article (10.1186/s13059-018-1408-2) contains supplementary material, which is available to authorized users.

Using institutional and behavioural economics to examine animal health systems

Economics provides a framework for understanding management decisions and their policy implications for the animal health system. While the neoclassical economic model is useful for framing animal health decisions on the farm, some of its assumptions and prescriptive results may be unrealistic. Institutional and behavioural economics address some of these potential shortcomings by considering the role of information, psychology and social factors in decisions. Framing such decisions under contract theory allows us to consider asymmetric information between policy-makers and farmers. Perverse incentives may exist in the area of preventing and reporting disease. Behavioural economics examines the role of internal and external psychological and social factors. Biases, heuristics, habit, social norms and other such aspects can result in farm decision-makers arriving at what might be considered irrational or otherwise sub-optimal decisions. Framing choices and providing relevant information and examples can alleviate these behavioural issues. The implications of this approach for disease policy and an applied research and outreach programme to respond to animal diseases are discussed.

Perceptions of randomness in binary sequences: Normative, heuristic, or both?

When people consider a series of random binary events, such as tossing an unbiased coin and recording the sequence of heads (H) and tails (T), they tend to erroneously rate sequences with less internal structure or order (such as HTTHT) as more probable than sequences containing more structure or order (such as HHHHH). This is traditionally explained as a local representativeness effect: Participants assume that the properties of long sequences of random outcomes-such as an equal proportion of heads and tails, and little internal structure-should also apply to short sequences. However, recent theoretical work has noted that the probability of a particular sequence of say, heads and tails of length n, occurring within a larger (>n) sequence of coin flips actually differs by sequence, so P(HHHHH) <P(HTTHT). In this alternative account, people apply rational norms based on limited experience. We test these accounts. Participants in Experiment 1 rated the likelihood of occurrence for all possible strings of 4, 5, and 6 observations in a sequence of coin flips. Judgments were better explained by representativeness in alternation rate, relative proportion of heads and tails, and sequence complexity, than by objective probabilities. Experiments 2 and 3 gave similar results using incentivized binary choice procedures. Overall the evidence suggests that participants are not sensitive to variation in objective probabilities of a sub-sequence occurring; they appear to use heuristics based on several distinct forms of representativeness.

Not that neglected! Base rates influence related and unrelated judgments

It is claimed that people are unable (or unwilling) to incorporate prior probabilities into posterior assessments, such as their estimation of the likelihood of a person with characteristics typical of an engineer actually being an engineer given that they are drawn from a sample including a very small number of engineers. This paper shows that base rates are incorporated in classifications (Experiment 1) and, moreover, that base rates also affect unrelated judgments, such as how well a provided description of a person fits a stereotypical engineer (Experiment 2). Finally, Experiment 3 shows that individuals who make both types of assessments - though using base rates to the same extent in the former judgments - are able to decrease the extent to which they incorporate base rates in the latter judgments.

False-positive results in pharmacoepidemiology and pharmacovigilance

False-positive constitute an important issue in scientific research. In the domain of drug evaluation, it affects all phases of drug development and assessment, from the very early preclinical studies to the late post-marketing evaluations. The core concern associated with this false-positive is the lack of replicability of the results. Aside from fraud or misconducts, false-positive is often envisioned from the statistical angle, which considers them as a price to pay for type I error in statistical testing, and its inflation in the context of multiple testing. If envisioning this problematic in the context of pharmacoepidemiology and pharmacovigilance however, that both evaluate drugs in an observational settings, information brought by statistical testing and the significance of such should only be considered as additional to the estimates provided and their confidence interval, in a context where differences have to be a clinically meaningful upon everything, and the results appear robust to the biases likely to have affected the studies. In the following article, we consequently illustrate these biases and their consequences in generating false-positive results, through studies and associations between drug use and health outcomes that have been widely disputed.

Fruit and vegetable intake: change with age across childhood and adolescence

Eating fruit and vegetables (FV) offers important health benefits for children and adolescents, but their average intake is low. To explore if negative trends with age exist as children grow, this study modelled differences in FV consumption from childhood to young adulthood. A pseudo-panel was constructed using years 1-4 (combined) of the Rolling Programme of the UK National Diet and Nutrition Survey (NDNS) (2008/2009-2011/2012). Intake of FV in the NDNS was recorded using 4-d unweighted food diaries. The data consisted of 2131 observations of individuals aged 2-23 years. Age-year-cohort decomposition regression analyses were used to separate age effects from year and cohort effects in the data. Total energy intake was included to account for age differences in overall energy consumption. Fruit intake started to decrease from the age of 7 years for boys and girls, and reached its lowest level during adolescence. By 17 years, boys were consuming 0·93 (P=0·037) less fruit portions compared with the age of 2 years. By 15 years, girls were consuming 0·8 fruit portions less (P=0·053). Vegetable intake changed little during childhood and adolescence (P=0·0834 and P=0·843 for change between 7 and 12 years, boys and girls, respectively). There was unclear evidence of recovery of FV intakes in early adulthood. Efforts to improve FV intake should consider these trends, and focus attention on the factors influencing intake across childhood and adolescence in order to improve the nutritional quality of diets during these periods.

Lessons learnt on biases and uncertainties in personal exposure measurement surveys of radiofrequency electromagnetic fields with exposimeters

Personal exposure measurements of radio frequency electromagnetic fields are important for epidemiological studies and developing prediction models. Minimizing biases and uncertainties and handling spatial and temporal variability are important aspects of these measurements. This paper reviews the lessons learnt from testing the different types of exposimeters and from personal exposure measurement surveys performed between 2005 and 2015. Applying them will improve the comparability and ranking of exposure levels for different microenvironments, activities or (groups of) people, such that epidemiological studies are better capable of finding potential weak correlations with health effects. Over 20 papers have been published on how to prevent biases and minimize uncertainties due to: mechanical errors; design of hardware and software filters; anisotropy; and influence of the body. A number of biases can be corrected for by determining multiplicative correction factors. In addition a good protocol on how to wear the exposimeter, a sufficiently small sampling interval and sufficiently long measurement duration will minimize biases. Corrections to biases are possible for: non-detects through detection limit, erroneous manufacturer calibration and temporal drift. Corrections not deemed necessary, because no significant biases have been observed, are: linearity in response and resolution. Corrections difficult to perform after measurements are for: modulation/duty cycle sensitivity; out of band response aka cross talk; temperature and humidity sensitivity. Corrections not possible to perform after measurements are for: multiple signals detection in one band; flatness of response within a frequency band; anisotropy to waves of different elevation angle. An analysis of 20 microenvironmental surveys showed that early studies using exposimeters with logarithmic detectors, overestimated exposure to signals with bursts, such as in uplink signals from mobile phones and WiFi appliances. Further, the possible corrections for biases have not been fully applied. The main findings are that if the biases are not corrected for, the actual exposure will on average be underestimated.

Right: Left:: East: West. Evidence that individuals from East Asian and South Asian cultures emphasize right hemisphere functions in comparison to Euro-American cultures

We present evidence that individuals from East or South Asian cultures (Japanese college students in Japan and East or South Asian born and raised college students in the USA) tend to exhibit default thinking that corresponds to right hemisphere holistic functions, as compared to Caucasian individuals from a Western culture (born and raised in the USA). In two lateralized tasks (locating the nose in a scrambled face, and global-local letter task), both Asian groups showed a greater right hemisphere bias than the Western group. In a third lateralized task, judging similarity in terms of visual form versus functional/semantic categorizations, there was not a reliable difference between the groups. On a classic, ambiguous face composed of vegetables, both Eastern groups displayed a greater right hemisphere (holistic face processing) bias than the Western group. These results support an "East - Right Hemisphere, West - Left Hemisphere" hypothesis, as originally proposed by Ornstein (1972). This hypothesis is open as to the degree to which social-cultural forces were involved in hemispheric specialization, or the opposite, or both. Our aim is to encourage a more thorough analysis of this hypothesis, suggesting both lateralization studies corresponding to documented East-West differences, and East-West studies corresponding to lateralization differences.

Differences in Biases and Compensatory Strategies Across Discipline, Rank, and Gender Among University Academics

The study of ethical behavior and ethical decision making is of increasing importance in many fields, and there is a growing literature addressing the issue. However, research examining differences in ethical decision making across fields and levels of experience is limited. In the present study, biases that undermine ethical decision making and compensatory strategies that may aid ethical decision making were identified in a series of interviews with 63 faculty members across six academic fields (e.g., biological sciences, health sciences, social sciences) and three levels of rank (assistant professor, associate professor, and full professor) as well as across gender. The degree to which certain biases and compensatory strategies were used in justifications for responses to ethical situations was compared across fields, level of experience, and gender. Major differences were found across fields for several biases and compensatory strategies, including biases and compensatory strategies related to use of professional field principles and field-specific guidelines. Furthermore, full professors tend to differ greatly from assistant and associate professors on a number of constructs, and there were differences in the consistency with which biases and compensatory strategies were displayed within these various groups. Implications of these findings for ethics training and future research are discussed.

Biased perception about gene technology: How perceived naturalness and affect distort benefit perception

In two experiments, the participants showed biased responses when asked to evaluate the benefits of gene technology. They evaluated the importance of additional yields in corn fields due to a newly introduced variety, which would increase a farmer's revenues. In one condition, the newly introduced variety was described as a product of traditional breeding; in the other, it was identified as genetically modified (GM). The two experiments' findings showed that the same benefits were perceived as less important for a farmer when these were the result of GM crops compared with traditionally bred crops. Mediation analyses suggest that perceived naturalness and the affect associated with the technology per se influence the interpretation of the new information. The lack of perceived naturalness of gene technology seems to be the reason for the participants' perceived lower benefits of a new corn variety in the gene technology condition compared with the perceptions of the participants assigned to the traditional breeding condition. The strategy to increase the acceptance of gene technology by introducing plant varieties that better address consumer and producer needs may not work because people discount its associated benefits.

If the results of an article are noteworthy, read the entire article; do not rely on the abstract alone

Clinicians typically update their knowledge by reading articles on the Internet. Easy access to the articles' abstracts and a lack of time to access other information sources creates a risk that therapeutic or diagnostic decisions will be made after reading just the abstracts. Occasionally, however, the abstracts of articles from clinical trials that have not obtained statistically significant differences in the primary study endpoint have reported other positive results, for example, of a secondary endpoint or a subgroup analysis. The article, however, correctly reports all results, including those of the primary endpoint. In the abstract, the safety information of the experimental treatment is usually deficient. The whole article should be read if a clinical decision is to be made.

What makes us think? A three-stage dual-process model of analytic engagement

The distinction between intuitive and analytic thinking is common in psychology. However, while often being quite clear on the characteristics of the two processes ('Type 1' processes are fast, autonomous, intuitive, etc. and 'Type 2' processes are slow, deliberative, analytic, etc.), dual-process theorists have been heavily criticized for being unclear on the factors that determine when an individual will think analytically or rely on their intuition. We address this issue by introducing a three-stage model that elucidates the bottom-up factors that cause individuals to engage Type 2 processing. According to the model, multiple Type 1 processes may be cued by a stimulus (Stage 1), leading to the potential for conflict detection (Stage 2). If successful, conflict detection leads to Type 2 processing (Stage 3), which may take the form of rationalization (i.e., the Type 1 output is verified post hoc) or decoupling (i.e., the Type 1 output is falsified). We tested key aspects of the model using a novel base-rate task where stereotypes and base-rate probabilities cued the same (non-conflict problems) or different (conflict problems) responses about group membership. Our results support two key predictions derived from the model: (1) conflict detection and decoupling are dissociable sources of Type 2 processing and (2) conflict detection sometimes fails. We argue that considering the potential stages of reasoning allows us to distinguish early (conflict detection) and late (decoupling) sources of analytic thought. Errors may occur at both stages and, as a consequence, bias arises from both conflict monitoring and decoupling failures.

Stability of self-referent encoding task performance and associations with change in depressive symptoms from early to middle childhood

Depressed individuals exhibit memory biases on the self-referent encoding task (SRET), such that those with depression exhibit poorer recall of positive, and enhanced recall of negative, trait adjectives (referred to as positive and negative processing biases). However, it is unclear when SRET biases emerge, whether they are stable, and if biases predict, or are predicted by, depressive symptoms. To address this, a community sample of 434 children completed the SRET and a depressive symptoms measure at ages 6 and 9. Negative and positive processing exhibited low, but significant, stability. At ages 6 and 9, depressive symptoms correlated with higher negative, and lower positive, SRET processing. Importantly, lower positive processing at age 6 predicted increased symptoms at age 9. However, negative processing at age 6 did not predict depressive symptoms at age 9, and depressive symptoms at age 6 did not predict SRET processing scores at age 9. This suggests that less positive processing may reflect vulnerability for future depressive symptoms.

A preliminary investigation of potential biases in phonation threshold pressure analysis

OBJECTIVE

Phonation threshold pressure (PTP) is a voice measure used in both research and clinic. PTP data analysis is susceptible to bias from investigator awareness of experimental hypothesis, and poor investigator training. The objective of this study was to systematically examine the role of these two biases on PTP data analysis.

STUDY DESIGN

Prospective design.

METHODS

Two trained investigators analyzed PTP datasets. The datasets were identical, but uniquely labeled so that the investigators were not aware that the datasets contained the same data. Each investigator analyzed two datasets. For one dataset, investigators were "blinded" to the experimental hypothesis. For the other dataset, the investigators were "unblinded" and provided a fake experimental hypothesis. Intraclass correlations were used to examine intrarater and interrater reliability.

RESULTS

For both investigators, intraclass correlations within the excellent range were obtained for intrarater reliability. In contrast, lower intraclass correlations were obtained for interrater reliability.

CONCLUSIONS

The high intrarater reliability obtained in this preliminary study suggests that awareness of experimental hypothesis may not significantly bias PTP analysis. Conversely, lower interrater reliability is indicative of differences between investigators analyzing the same data. Our findings contribute to the growing body of literature that seeks to standardize the use of PTP in research and the clinic. Future investigations are needed to identify methods to improve interrater reliability and that quantify the effects of biases on PTP data collection.

[Introduction to critical reading of articles: study design and biases]

The critical evaluation of an article enables professionals to make good use of the new information and therefore has direct repercussions for the benefit of our patients. Before undertaking a detailed critical reading of the chosen article, we need to consider whether the study used the most appropriate design for the question it aimed to answer (i.e., whether the level of evidence is adequate). To do this, we need to know how to classify studies in function of their design (descriptive or analytical; prospective or retrospective; cross-sectional or longitudinal) as well as their correlation with the levels of evidence. In critical reading it is also important to know the main systematic errors or biases that can affect a study. Biases can appear in any phase of a study; they can affect the sample, the development of the study, or the measurement of the results.

Biases in preferences for sequences of outcomes in monkeys

Movies, vacations, and meals are all examples of events composed of a sequence of smaller events. How do we go from our evaluations of each scene in a movie to an evaluation of the sequence as a whole? In theory, we should simply average the values of the individual events. In practice, however, we are biased towards sequences where each element tends to be better than the previous, where the last value is large, and we overweight the best (or worst) part of the sequence. To study how general these biases are we examined monkeys' preferences for sequences of rewards in a novel reward repeat task. Monkeys were first given a sequence of rewards and then chose between repeating the sequence or receiving a standard comparator sequence. We found that, like humans, monkeys overweight events that happen later in a sequence, so much so that adding a small reward to the end of a sequence can paradoxically reduce its value. Monkeys were also biased towards sequences with large peak values (the highest value in the sequence), but only following a working memory challenge, suggesting that this preference may be driven by memory limitations. These results demonstrate the cross-species nature of biases in preferences for sequences of outcomes. In addition, monkeys' consistent preference for sequences in which large values occur later challenges the generality of discounting models of intertemporal choice in animals.

Correcting Psychotherapists' Blindsidedness: Formal Feedback as a Means of Overcoming the Natural Limitations of Therapists

PURPOSE

Monitoring of client progress in psychological therapy using formal outcome measures at each session has been shown to increase the effectiveness of treatment. It seems likely that this 'feedback' effect is achieved by enabling therapists to identify clients at risk of treatment failure so that therapists can pay greater attention to client difficulties, which may be hindering therapeutic work. To date, little attention has been given to understanding relevant mechanisms of formal feedback in psychological therapy. In order to understand and maximize the benefits of feedback, it is essential to explore potential mechanisms contributing to this effect. Research in social psychology may help to explain how feedback works.

METHODS

Findings on cognitive biases in the field of social psychology are explored and linked to preliminary findings in the field of psychotherapy research.

RESULTS

Research on cognitive biases and expertise is congruent with indications that clinical prediction in psychotherapy is unreliable and that it may be difficult for clinicians to detect errors in their judgement as a result of a lack of clear corrective feedback. This problem is linked to the fact that clinical outcomes occur in a complex 'noisy' environment where prediction is inherently difficult.

CONCLUSION

Formal feedback may derive its benefits from its ability to help correct naturally occurring biases in therapists' assessment of their work. If these biases are seen as normal, but often avoidable if feedback is used, this may pave the way to greater acceptance of formal feedback by clinicians and enhanced outcomes for clients.

KEY PRACTITIONER MESSAGE

The use of formal feedback tools can help therapists overcome inevitable limitations in their ability to predict poor response to treatment, enhancing the likelihood of detecting and resolving client difficulties in therapy.