Heuristics, biases, and cognitive pitfalls of emergency teledermatology: Navigating the fine line between making and avoiding diagnostic errors

Dear Editors, With the rapidly expanding use of store-and-forward teledermatology (SFTD), dermatologic emergencies are increasingly likely to be managed through SFTD rather than during in-person emergency visits.1, 2 As tele-emergency is integrating into our routine dermatological care, it is imperative to maximize avoidance of pitfalls and biases that may lead to diagnostic errors. Since diagnostic errors are a substantial source of avoidable illness and death,3 dermatologists practicing tele-emergency have to understand their underpinnings to anticipate and prevent them. Rapid decision-making is facilitated by heuristics, i.e., mental shortcuts that reduce task complexity, but constrained by biases, i.e., the discrepancies between normative and heuristically driven behaviors.4 Taking correct decisions in SFTD relies on asking the most appropriate questions, accurately interpreting the answers, and knowing when to stop searching further. Although this may sound simple, reliance on heuristics and susceptibility to biases can create pitfalls throughout the cognitive process (Figure 1).5, 6 The representativeness heuristic is one such pitfall, relying on similarity to a prototype.7 It is applied when the likelihood of an event is judged by its similarity to a mental prototype. For example, a teledermatologist receiving images of a patient on anticonvulsants with a bullous eruption may diagnose Stevens–Johnson syndrome (SJS) because this presentation resembles the prototype of patients with such a combination (anticonvulsant use and bullous eruption). To avoid the representativeness heuristic, teledermatologists must consider not only the likelihood of a diagnosis such as SJS based on situational information (e.g., a patient receiving anticonvulsants), but also its likelihood in the absence of that information. Probability judgments may also be distorted by the availability heuristic,8 whereby the perceived likelihood of an event is influenced by how readily it comes to mind. For example, after recently encountering a case of necrotizing fasciitis (NF), a teledermatologist may overestimate its frequency and increase the rate of NF diagnoses. To avoid being misled by the availability heuristic, teledermatologists should critically assess whether the information provided is truly relevant to the diagnosis or merely reflects a recent or memorable case. Another pitfall that can affect SFTD is anchoring heuristic, which refers to favoring information received early in the decision-making process.8 For example, focusing on the information of “a recent trauma” given by the requesting physician might stop further investigations or exams in a patient with subungual melanoma. To avoid falling prey to the anchoring heuristic, teledermatologists should actively challenge initial anchors and adjust their estimates accordingly. This helps prevent premature closure of the diagnostic process due to reliance on misleading information. In store-and-forward teledermatology (SFTD), practitioners must also guard against confirmation bias, the cognitive tendency to place disproportionate weight on information supporting a preliminary diagnosis while overlooking or neglecting contradictory evidence.10 Requesting physicians may explicitly ask to confirm a suspected diagnosis, for example, drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome. In such cases, teledermatologists may overvalue data consistent with DRESS in their cognitive process. Debiasing strategies include actively seeking information that challenges the initial diagnosis provided by the requester. The final, and perhaps most consequential, bias is overconfidence, a potentially fatal pitfall. Overconfidence arises from overestimating one's skills and assuming immunity to error. Physicians generally struggle to recognize gaps in their knowledge.4 In SFTD, teledermatologists should learn to reassess and reconsider their diagnoses when appropriate, viewing this not as a deficit in substantive knowledge but as an inherent limitation of SFTD performance. Because SFTD requests are typically initiated by non-dermatologists, the risk of pitfalls is compounded, as the cognitive process is influenced by the biases of both physicians. Excessive weight may be placed on particular pieces of information provided by the requesting physician. This can highly mislead teledermatologists in urgent settings and result in overdiagnosis of dermatological emergencies by fear of missing life-threatening conditions. Similarly, missing crucial information can lead to underdiagnosis of serious problems. The absence of direct history taking and physical examination by the dermatologist may, in some cases, skew cognitive judgment toward the requester's diagnosis. To mitigate this risk, and in view of the biases discussed above, we developed a checklist designed to help dermatologists avoid such pitfalls, as presented in Table 1. Ultimately, recognizing and counteracting heuristics and biases is not merely an academic exercise but an essential safeguard in tele-emergency dermatology. By incorporating structured strategies, such as the proposed checklist, teledermatologists can reduce diagnostic errors, mitigate risks associated with the absence of physical examination, and ensure that urgent cases are managed with the accuracy and timeliness they require. In this way, digital health can realize its promise of providing safe, effective, and equitable care. None.