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Difficulty: HardHuman Factors and Cognitive Biases

A 68-year-old man is evaluated in the surgical step-down unit due to tachycardia. He was transferred from the intensive care unit (ICU) earlier this morning, which is postoperative day 3 following an open abdominal aortic aneurysm repair. During the morning verbal handoff, the night-shift intensivist told the receiving physician, "The patient had some mild tachycardia overnight, but it is just expected postoperative incisional pain; we plan to optimize his epidural." Upon evaluation 3 hours later, the patient's heart rate is 125/min and blood pressure is 88/58 mmHg. He complains of vague, diffuse abdominal discomfort and back pain. The receiving physician documents, "Tachycardia secondary to inadequately controlled pain," and immediately orders an epidural local anesthetic bolus without reviewing the patient's recent hemoglobin level or ordering new laboratory studies. Later that evening, the patient develops profound hemorrhagic shock due to a retroperitoneal bleed. Which of the following cognitive biases best explains the receiving physician's initial decision-making process?

  1. Anchoring biasAnswer
  2. B
    Availability heuristic
  3. C
    Confirmation bias
  4. D
    Framing effect
  5. E
    Premature closure

Answer

Anchoring bias
The correct answer is anchoring bias. Anchoring bias occurs when a clinician relies too heavily on the first piece of information provided (the "anchor") and fails to adequately adjust their thinking when new or contradictory information becomes available. In this scenario, the receiving physician anchored on the night-shift intensivist's diagnosis of "expected postoperative incisional pain." Despite the patient developing new, alarming objective findings (hypotension of 88/58 mmHg and back pain), which strongly suggest a catastrophic complication like retroperitoneal bleeding following an aortic procedure, the physician failed to adjust the differential diagnosis and inappropriately initiated isolated pain management.

Step-by-Step Solution

1
Analyze the clinical scenario to identify the source of the medical error.
The physician ignored new objective findings (hypotension and back pain), incorrectly attributing the tachycardia entirely to pain based on the ICU handoff report.
Identifying the mismatch between the objective clinical data and the physician's documented rationale reveals the underlying cognitive flaw.
2
Differentiate between the provided cognitive biases based on the physician's thought process.
The error stems directly from an inability to move away from an initial piece of provided information (the handoff diagnosis of 'pain').
Distinguishing between cognitive biases requires mapping the specific action (relying on the handoff) to the psychological definition.
3
Match the identified thought process to the correct cognitive bias.
Relying too heavily on an initial diagnostic label and failing to adjust despite contradictory evidence is the definition of anchoring bias.
This confirms the specific cognitive bias driving the diagnostic error.

Key Concept

Identification of specific cognitive biases contributing to diagnostic errors in clinical practice, particularly during transitions of care.
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Topics

Human Factors and Cognitive Biases

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