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Difficulty: HardHuman Factors and Cognitive Biases

A 42-year-old woman is evaluated in the emergency department for progressive shortness of breath and a dry cough over the past week. She has a history of poorly controlled asthma and obesity. Over the past month, the region has experienced unprecedented wildfires, and the evaluating physician has managed dozens of severe asthma exacerbations. Upon initial assessment, the physician notes bilateral wheezing, immediately diagnoses an asthma exacerbation, and prescribes systemic corticosteroids and continuous bronchodilator nebulization.

Two hours later, the patient's hypoxia worsens despite therapy. The physician returns to the bedside and specifically questions the patient about her recent compliance with home inhalers and whether she has been keeping her windows open at home. During this conversation, the physician disregards the patient's new complaint of sharp, right-sided pleuritic chest pain, attributing it to muscle strain from forceful coughing. A subsequent CT pulmonary angiogram, ordered by a different physician during shift change, reveals a large saddle pulmonary embolism.

Which of the following cognitive biases best explains the initial physician's persistent focus on an asthma exacerbation despite the patient's worsening clinical trajectory and new symptoms?

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

Answer

Confirmation bias
The correct answer is confirmation bias. Confirmation bias is the tendency to search for, interpret, favor, and recall information in a way that confirms one's preexisting beliefs or hypotheses while giving disproportionately less consideration to alternative possibilities. In this vignette, the physician formed an initial hypothesis (asthma exacerbation) and subsequently maintained this incorrect diagnosis by actively seeking confirming evidence (questioning about inhaler compliance and window exposure) while simultaneously ignoring and rationalizing away contradictory evidence (dismissing the new right-sided, sharp chest pain as a mere muscle strain). This selective data filtering prevented the physician from reconsidering the diagnosis and broadening the differential to include pulmonary embolism.

Step-by-Step Solution

1
Analyze the physician's initial diagnostic process.
The physician diagnosed an asthma exacerbation, likely influenced by the recent high volume of similar cases (availability heuristic).
To identify the starting point of the diagnostic error.
2
Evaluate the physician's actions during the clinical reassessment.
The physician actively sought data to support the asthma diagnosis (inhaler compliance) and dismissed contradictory data (attributing new pleuritic chest pain to muscle strain).
To determine which cognitive bias maintained the error despite the patient's worsening status.
3
Differentiate between the cognitive biases presented in the options.
The selective seeking of supportive evidence and rationalization of conflicting clinical evidence perfectly aligns with confirmation bias.
To select the most accurate term for the physician's specific behavior described in the prompt.

Key Concept

Distinguishing between the cognitive biases that initiate diagnostic errors versus those that maintain them, specifically identifying confirmation bias in clinical reassessment.
Estimated Time:1m 30s
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Topics

Human Factors and Cognitive Biases

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