The role of physicians’ first impressions in the diagnosis of possible cancers without alarm symptoms

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Title: The role of physicians’ first impressions in the diagnosis of possible cancers without alarm symptoms
Authors: Kostopoulou, O
Sirota, M
Round, T
Samaranayaka, S
Delaney, BC
Item Type: Journal Article
Abstract: Background. First impressions are thought to exert a disproportionate influence on subsequent judgments; however, their role in medical diagnosis has not been systematically studied. We aimed to elicit and measure the association between first impressions and subsequent diagnoses in common presentations with subtle indications of cancer. Methods. Ninety UK family physicians conducted interactive simulated consultations online, while on the phone with a researcher. They saw 6 patient cases, 3 of which could be cancers. Each cancer case included 2 consultations, whereby each patient consulted again with nonimproving and some new symptoms. After reading an introduction (patient description and presenting problem), physicians could request more information, which the researcher displayed online. In 2 of the possible cancers, physicians thought aloud. Two raters coded independently the physicians’ first utterances (after reading the introduction but before requesting more information) as either acknowledging the possibility of cancer or not. We measured the association of these first impressions with the final diagnoses and management decisions. Results. The raters coded 297 verbalizations with high interrater agreement (Kappa = 0.89). When the possibility of cancer was initially verbalized, the odds of subsequently diagnosing it were on average 5 times higher (odds ratio 4.90 [95% CI 2.72 to 8.84], P < 0.001), while the odds of appropriate referral doubled (OR 1.98 [1.10 to 3.57], P = 0.002). The number of cancer-related questions physicians asked mediated the relationship between first impressions and subsequent diagnosis, explaining 29% of the total effect. Conclusion. We measured a strong association between family physicians’ first diagnostic impressions and subsequent diagnoses and decisions. We suggest that interventions to influence and support the diagnostic process should target its early stage of hypothesis generation.
Issue Date: 25-Apr-2016
Date of Acceptance: 17-Mar-2016
ISSN: 1552-681X
Publisher: SAGE Publications
Start Page: 9
End Page: 16
Journal / Book Title: Medical Decision Making
Volume: 37
Issue: 1
Copyright Statement: The Author(s) 2016. This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 3.0 License ( which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page(
Sponsor/Funder: Cancer Research UK
Funder's Grant Number: C33754/A12222
Keywords: cognitive psychology
family medicine
heuristics and biases
provider decision making
Health Policy & Services
1117 Public Health And Health Services
1402 Applied Economics
Publication Status: Published
Open Access location:
Appears in Collections:Division of Surgery
Faculty of Medicine

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