Physicians' metacognition in medical decision-making

A large literature reports that physicians are overconfident when making medical decisions. However, the validity of these findings is questioned due to methodology pitfalls leading to poor ecological validity. Moreover, most previous studies do not distinguish between (i) metacognitive bias, the general tendency to report high or low confidence irrespectively of actual accuracy, and (ii) metacognitive sensitivity, the capacity to discriminate between one's own correct and incorrect decisions. Here, we aim to overcome these limitations by drawing from state-of-the-art paradigms and tools from the cognitive science of metacognition. To examine overconfidence and to disentangle metacognitive bias from metacognitive sensitivity, we developed a carefully controlled set of case-vignettes of patients with headaches that was completed by 52 physicians. We found that physicians' confidence, reliably discriminated their correct from their incorrect decisions, demonstrating genuine metacognitive sensitivity. However, physicians were also overconfident, and this overconfidence was most pronounced among the least accurate participants. Moreover, the costliest errors (i.e. missed urgent cases) were held with higher confidence than unnecessary referrals. Finally, unlike previous reports, we found limited interindividual variability depending on specialty, gender, or seniority level, although our study was not powered for these comparisons.