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Difficulty: Very hardHuman Factors and Cognitive Biases

A 42-year-old woman presents to an urgent care clinic with sudden-onset shortness of breath and pleuritic chest pain. Upon rooming the patient, the medical assistant hands the chart to the physician and states, "The patient in room 2 is here for an anxiety attack, just like the one she had last month." The physician enters the room and immediately assumes the patient's dyspnea is secondary to a panic disorder exacerbation. To confirm this suspicion, the physician focuses the interview strictly on eliciting a history of recent psychological stressors and feelings of impending doom. During the physical examination, the patient repeatedly attempts to report a new, deep aching pain in her right calf that began the previous day. The physician dismisses this information, assuring the patient that muscle tension is a normal somatic manifestation of severe anxiety. The patient is discharged with a lorazepam prescription. Twelve hours later, she is brought to the emergency department in obstructive shock due to a massive saddle pulmonary embolism.

Which of the following cognitive errors most heavily contributed to the physician's diagnostic failure? (Select exactly two options)

  1. Anchoring biasAnswer
  2. B
    Availability heuristic
  3. Confirmation biasAnswer
  4. D
    Framing effect
  5. E
    Representativeness heuristic

Answer

The correct answers are Anchoring bias and Confirmation bias.
The physician's diagnostic error was driven by two sequential cognitive biases. First, anchoring bias occurred when the physician fixated on the medical assistant's initial triage statement ('anxiety attack'). Instead of treating this as one possibility, the physician used it as an anchor. Second, confirmation bias occurred during the patient encounter. The physician selectively guided the interview to elicit psychological symptoms that supported the anchored diagnosis, while actively dismissing objective, contradictory clinical information (calf pain, highly suspicious for deep vein thrombosis preceding a pulmonary embolism).

Step-by-Step Solution

1
Analyze the initial interaction between the physician and the medical assistant.
The medical assistant provided an initial diagnosis ('anxiety attack'), which the physician immediately accepted as the primary hypothesis.
This establishes the presence of anchoring bias, where the first piece of information disproportionately influences subsequent decision-making.
2
Evaluate the physician's interview and physical examination approach.
The physician exclusively sought psychological history and dismissed the patient's report of unilateral calf pain as 'muscle tension'.
This demonstrates confirmation bias, as the physician selectively gathered data to support the anchored hypothesis while actively rejecting clinical data that suggested an alternative, life-threatening diagnosis (deep vein thrombosis/pulmonary embolism).
3
Differentiate the observed behaviors from other cognitive biases.
The scenario does not describe the physician relying on recent memorable cases (availability), responding to statistical presentation of risk (framing), or pattern-matching against a prototype (representativeness).
Accurate identification of cognitive biases requires matching the specific physician behaviors to the precise definitions of human factors in medical error.

Key Concept

Diagnostic errors often result from a cascade of cognitive biases, most notably anchoring bias (fixating on initial information) followed by confirmation bias (selectively gathering data to support the initial hypothesis while dismissing contradictory evidence).
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Topics

Human Factors and Cognitive Biases

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