Step one is to recognize that many heuristics are essentially abbreviations of full conscious reasoning. Now take a physician who is tired, stressed, or inundated with multiple tasks. In an effort to organize the seemingly chaotic world of medicine the mind seeks a crutch. These mental shortcuts allow us to quickly process massive amounts of information and come up with a reasonable plan that will be right most of the time.
When rushed, stressed, and distracted, we are most prone to use these shortcuts. These times of pressure are exactly when it is most important to pause and consider whether we’re acting on gut feeling or on full consideration of all the evidence. Awareness of the predictable circumstances that create the set-up for heuristic failures allows for a moment of reflection to prevent falling into one of these psychological traps. This process of deliberately considering our own decision-making is referred to as meta-cognition.
An additional familiar tool available to the physician is differential diagnosis. This is essentially a form of cognitive forcing strategy designed to guard against availability and anchoring biases. By deliberately creating a list of alternative possibilities, we become less prone to anchor on a single diagnosis.
By briefly reviewing the rare possibilities we have not seen recently and bringing them to the forefront of memory, we diminish the power of the availability bias. Spending a second or two considering the differential—even in seemingly routine cases—will defuse the hold of these particular heuristics.
Hospitalists by the nature of our practice tend to have multiple transitions in patient care. At times this offers a fresh perspective to correct mistakes, but it also offers potential to compound them via diagnosis momentum.
We habitually convey diagnosis and treatment plans to our partners at handoffs. Including a level of uncertainty as part of checkout would create a cue for the accepting physician to decrease the risk of this heuristic failure. One might imagine the patient in the case above would have had a greater probability of survival if the nocturnist had conveyed a diagnosis of “chest pain of uncertain etiology” to his partner rather than “chest pain rule-out MI.”
As illustrated by the cases above, heuristics are not mistakes in and of themselves. They are the assumptions and pattern-recognition techniques that serve us well the majority of the time in and out of medicine. Recognizing when you take one of these mental shortcuts, being aware of the circumstances that predispose to error creation, and evaluating your decision-making process allows the astute physician to guard against the times when they fail. Greater self-awareness of the process of your own cognition can make for a better clinician—and perhaps even make you a better investor. TH
Drs. Cumbler and Trosterman are assistant professors in the Section of Hospital Medicine at the University of Colorado.