PURPOSE
Diagnostic error remains a critical challenge in emergency medicine, where
decisions occur under high acuity, time pressure, and uncertainty. Cognitive
biases, unconscious thought patterns that distort judgment, are
well-documented among physicians and trainees but understudied in physician
assistants (PAs) and PA students, despite their growing role in patient care.
This study explores emergency department (ED) preceptors’ perceptions of PA
students’ diagnostic reasoning during clinical rotations.
METHODS
Guided by dual-cognition theory, which distinguishes intuitive (System 1)
and analytical (System 2) reasoning, this qualitative study examined how
preceptors identify and address heuristic-driven biases such as anchoring and
premature closure. Ten ED preceptors from diverse clinical settings
participated in semi-structured interviews. Data were analyzed using a hybrid
coding approach, combining deductive and inductive methods. A priori codes
focused on diagnostic strengths, challenges, patient safety implications, and
instructional strategies.
RESULTS
Three major themes emerged:
 
 Patient and Illness Characteristics:
High complexity, acuity, and atypical presentations increased diagnostic
difficulty for PA students.
 Student Characteristics and Cognitive
Biases: Preceptors observed premature closure, anchoring, limited
emergency-specific differential diagnoses, and overreliance on pattern
recognition.
 Preceptor Interventions and
Feedback: Effective strategies included real-time correction, structured
feedback, case-based learning, and promoting self-reflection. Subthemes
emphasized strengthening history-taking and diagnostic formulation through
repetition, targeted instruction, and experiential learning.
CONCLUSIONS
Findings highlight opportunities to enhance PA diagnostic education by
integrating cognitive bias awareness into curricula, leveraging simulation
and case-based learning, and exploring innovative methods such as
gamification and AI-assisted feedback. This study contributes to the limited
literature on PA diagnostic reasoning and offers actionable insights for
educators and clinical preceptors. Future research should evaluate specific
teaching interventions, track diagnostic performance longitudinally, and
foster interdisciplinary collaboration in curriculum design to improve
diagnostic competence and patient safety.