Cognitive and Gender Biases Affect Primary Care Spondyloarthritis Diagnoses in Simulations

Primary care physicians assessing simulated clinical cases correctly identified axial spondyloarthritis in 11 out of 12 participants evaluating a female patient and in 7 out of 10 evaluating a male patient.

In contrast to the axial evaluations, none of the participating clinicians correctly diagnosed peripheral spondyloarthritis cases, regardless of the simulated patient’s sex.

The qualitative study evaluated 46 primary care physicians from the Spanish National Health System using an online structured electronic questionnaire to analyze clinical reasoning, decision-making, and diagnostic biases in spondyloarthritis.

Participants reviewed four sequential case-based simulations: a 30-year-old male or female patient presenting with one year of low back pain representing axial spondyloarthritis, and a 25-year-old male or female patient presenting with three months of left knee and ankle pain representing peripheral spondyloarthritis.

Distinct diagnostic reasoning patterns emerged based on patient sex, with axial spondyloarthritis symptoms initially interpreted as functional by 6 out of 12 clinicians in female cases compared to 3 out of 10 in male cases.

This gender bias manifested as a tendency among clinicians to attribute young women’s symptoms to psychological or nonspecific causes when overt red flags were perceived to be absent.

Diagnostic assessments also revealed patterns consistent with anchoring bias, wherein clinicians persisted with initial interpretations even after objective inflammatory markers were reported, despite these tests often not being initially requested.

In peripheral spondyloarthritis cases, reasoning demonstrated availability bias shaped by familiarity with sex- and age-related conditions, frequently misclassifying female presentations as juvenile arthritis or vague inflammatory syndromes, while male cases were misclassified as reactive arthritis or mechanical disorders due to emphasis on contextual factors such as sexual history or occupational strain.

The study concluded that primary care diagnostic reasoning for spondyloarthritis is shaped by implicit biases related to sex, age, and context alongside clinical evidence, highlighting the need for targeted educational strategies that foster reflective practice and integrate a gender-sensitive approach into clinical judgment.

Subject of Research: Diagnostic reasoning and cognitive biases in primary care spondyloarthritis assessment

Article Title: Cognitive and gender bias in primary care spondyloarthritis diagnosis: case simulation-based research

Article References: Ruiz-Cantero, M. T., Jovani, V., Pérez-Jover, V., Román, C. J. V.-D. H., Andrés, L. G., Gómez Santana, M. D. C., Rodríguez-Gimena, M. D. M., Zamora, A., & Salvador-Sánchez, L. (2026). Cognitive and gender bias in primary care spondyloarthritis diagnosis: case simulation-based research. BMC Primary Care. https://doi.org/10.1186/s12875-026-03616-8

Image Credits: AI Generated

DOI: 10.1186/s12875-026-03616-8

Keywords: spondyloarthritis, axial spondyloarthritis, peripheral spondyloarthritis, primary care, diagnostic reasoning, cognitive bias, gender bias, clinical simulation, Cognitive, gender, bias, primary