When psychiatrists offer expert opinions, such as in malpractice cases
involving suicide or violence, they should, of course, do so objectively.
Nonetheless, they may be subject to hindsight bias, a study in the March
Journal of the American Academy of Psychiatry and the Law
Hindsight bias is the tendency for persons who already know an outcome to
exaggerate the degree to which they had predicted it. In common parlance, one
might call it "Monday-morning quarter-backing."
The lead investigator was Herbert LeBourgeois III, M.D., an assistant
professor of psychiatry at Tulane University, and the senior investigator was
Paul Appelbaum, M.D., a professor of psychiatry, medicine, and law at Columbia
University and a former APA president.
Each of 231 psychiatrists participating in the study was asked to assess
risk in a hypothetical case of suicidal ideation and in a hypothetical case of
homicidal ideation. Half the subjects were told in advance that the
hypothetical patients eventually committed suicide or homicide; the other half
were not told this.
The group that had been told the patients' outcome in advance rated them at
a higher risk of suicide and violence than did the group that had not been so
alerted. The difference was statistically significant, a finding that the
investigators had anticipated, especially since a previous study had found
that when anesthesiologists review cases with adverse anesthetic outcomes,
they are vulnerable to hindsight bias.
This result, LeBourgeois told Psychiatric News, "has
potential relevance to psychiatrists providing opinions in malpractice cases
(or peer-review evaluations) involving suicide or violence. If, during such
retrospective evaluations, evaluating psychiatrists unknowingly exaggerate the
risk of suicide or violence posed by patients, they could overestimate the
causal role of the actions or omissions of the psychiatrist under
Other findings from the study suggest that even if psychiatrists are
susceptible to bias in estimating suicide or violence risk, they may not
necessarily be biased in determining whether the psychiatrist caring for the
patient at risk was negligent.
Specifically, the group that had been told in advance about the outcomes in
the two hypothetical cases was asked to determine whether the psychiatrists
caring for the patients had been negligent. The group that had not been told
in advance of the outcome was asked to do the same. There were no
statistically significant differences between the assessments of the two
groups, implying that hindsight bias did not affect this particular type of
This was "a somewhat reassuring result," the investigators said
in their report, because it suggested that "ultimate determinations of
negligence in malpractice cases may be less affected by hindsight bias than
estimates of violence or suicide risk are."
Another notable finding emerged regarding psychiatrists who specialize in
forensic psychiatry. The investigators examined hindsight-bias results
depending on whether subjects were members of the American Academy of
Psychiatry and the Law (AAPL) or members of only APA. Although both AAPL and
APA subjects who had been told in advance about outcomes were more susceptible
to hindsight bias than were their control counterparts, the difference was
statistically significant only for the APA-member group.
This finding surprised him, LeBourgeois said. It suggests "that
forensic training, forensic experience, or ongoing continuing medical
education related to forensic work may serve as buffers to hindsight
"The data suggest a good news/bad news picture," Appelbaum
added. "Psychiatrists are not immune from hind-sight bias when assessing
malpractice cases—that's the bad news. It means that defendant
psychiatrists may be at risk of judgments... that are not entirely fair.
However, the good news is that greater familiarity with the forensic setting
seems to neutralize the biasing effect of knowing the outcome. This suggests
that psychiatrists without forensic training who are considering acting as
expert witnesses in malpractice cases would be wise to get some significant
degree of education and supervised experience first."
The study had no external sources of funding.
An abstract of "Hindsight Bias Among Psychiatrists" is
J Am Acad Psychiatry Law