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Difficulty: MediumHuman Factors and Cognitive Biases

A 62-year-old man is recovering on the surgical ward two days after a right total hip arthroplasty. During the morning sign-out, the night-shift resident informs the day-shift physician, 'The patient developed tachycardia overnight, which is likely just secondary to postoperative pain and anxiety. I administered PRN analgesics.' Upon evaluating the patient, the day-shift physician assumes the tachycardia is pain-related. When the patient mentions experiencing mild chest discomfort, the physician attributes it to prolonged bed rest and positioning. An electrocardiogram is obtained and shows non-specific ST-segment changes. The physician quickly reviews the tracing, documenting that the findings are 'likely his baseline,' and decides not to order cardiac biomarkers or a computed tomography pulmonary angiogram. Later that afternoon, the patient suffers a cardiac arrest secondary to a massive myocardial infarction. Which of the following cognitive biases most significantly contributed to the day-shift physician's diagnostic error? (Select all that apply)

  1. Anchoring biasAnswer
  2. Confirmation biasAnswer
  3. C
    Availability heuristic
  4. D
    Framing effect
  5. E
    Affect heuristic

Answer

Anchoring bias and Confirmation bias
In this scenario, two primary cognitive biases lead to the adverse outcome. First, the day-shift physician exhibits anchoring bias by heavily relying on the night-shift resident's initial assessment ('pain and anxiety') rather than independently evaluating the cause of the tachycardia. Second, the physician demonstrates confirmation bias by selectively interpreting new, ambiguous data—specifically the patient's chest discomfort and the non-specific EKG changes—as benign findings that support the initial, anchored hypothesis, thereby failing to work up a potentially fatal postoperative complication.

Step-by-Step Solution

1
Analyze the source of the initial misdiagnosis in the clinical vignette.
The day-shift physician unquestioningly accepts the night-shift resident's handoff that the tachycardia is due to 'pain and anxiety.'
Relying heavily on an initial piece of information or another provider's prior assessment defines anchoring bias.
2
Evaluate how the physician handles new or ambiguous clinical information during the patient encounter.
The physician dismisses new chest discomfort as positional and assumes non-specific EKG changes are merely 'baseline' without objective verification.
Selectively interpreting new data to fit a preconceived hypothesis, rather than considering alternative diagnoses like myocardial infarction or pulmonary embolism, defines confirmation bias.
3
Rule out other cognitive biases.
The scenario lacks elements of recent memorable events (availability), emotional influence (affect), or presentation of statistics (framing).
This ensures the selected biases are the primary drivers of the specific diagnostic error presented.

Key Concept

Cognitive biases in diagnostic reasoning, specifically how handoff communication can introduce anchoring and subsequently lead to confirmation bias.
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Topics

Human Factors and Cognitive Biases

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