Anchoring Heuristics

A few years ago I decided to go back to college to obtain my bachelors degree in psychology. I am often asked why I chose this field of study. "Do you plan on becoming a shrink?"

The answer is.. probably not.

Yet, the study of psychology has helped me tremendously when meditating on certain behaviors and decisions in medicine. 

Medical errors are commonly portrayed as individualistic faults that manifest from either a lack of training or diligence. Application and understanding of cognitive psychology can partially explain the reason smart people make simple mistakes.

If this stuff interests you, I encourage you to check out a 2005 article published in Annals of Internal Medicine titled “ The cognitive psychology of missed diagnosis.” In this paper Donald Redelmeier unpacks the logistics and heuristics of clinical decision making. Contrasting cognitive psychology with other psychological paradigms (e.g. humanistic and psychoanalysis) can provide further insight into clinical error. 

Brain-Lag

When a computer has multiple tabs or programs running at once, there can be a frustrating lag that occurs. Cognitive psychology and anecdotal experience support the fact that the human brain experiences a similar processing lag when choices or stimuli accumulate.

In order to increase cognitive bandwidth, clinicians will develop mental shortcuts known as heuristics. Heuristics are decisions based on familiar patterns we have experienced. Humans repeating actions and mentally recording the effect, was noted by Swiss developmental psychologist Jean Piaget, as “circular reactions."

Illustration by Hugo Lin. © Verywell, 2018.

When studying infants, Piaget noted mental shortcuts that were formed when the infant experienced the cause and effect of actions. When this theory of mental shortcuts is applied to medicine, it allows rapid life-saving interventions to be performed with incredible pace.

Let's try one out! How fast does a differential come to mind when you look at the picture below?

You likely did not hesitate to analyze the complaint/story and patient demographics to produce a suspision of an acute myocardial infarction. Your brain has created shortcuts based on previous experiences or experience of others. Let's try another one!

Don't feel bad if drug use was your first thought! Your brain has seen enough of these that it has attempted to create a mental shortcut. This is called recognition primed decision making (Klein, 1998). While it works a lot of the time, it is not flawless. 

Occasionally clinicians can fall victim to anchoring heuristics and diagnostic momentum. Perhaps a humanistic approach to psychology could explain why this occurs. 

Abraham Maslow, an American psychologist in the 1900’s commonly known for his theory of self-actualization, postulated that humans have specific needs that must be fulfilled before they can reach self-actualization.

For example, consider an EMS provider who is having personal health issues. Pre-existing experience and heuristics may lag in processing information even when providing routine care. Anchoring on a specific diagnosis and tunnel vision is a hallmark symptom of decision fatigue and accumulative stress.

In aviation it’s commonly taught that human error is a symptom of a deeper systemic flaw. Rather than blaming the individual, diligence should be made to evaluate why the error occurred.

Maslow reminds us that sometimes the system issue is internal and/or individualized to basic needs. However, even if all essential needs are satisfied, specific presentations or sensatory stimulation may exacerbate emotion from repressed experiences or memories (Wortham, 2017) . This type of error is harder to detect from pure external observation.

An unconscious emotion manifested by repressed experiences is best described through psychoanalysis, a theory proposed by neurologist, Sigmund Freud (Goodwin, 2015). Freudian resistance was a term developed to describe an individual who avoids specific topics (consciously or unconsciously) due to previous experiences. When contrasted with an EMS provider or healthcare worker - one may defer a specific skill or medication based off poor anecdotal experience.

Surfacing  and vocalizing memories that connect a frightening experience to trepidation was suggested by Freud to be the first step in eliminating repressed emotion. But getting individuals comfortable enough to accurately reflect on an emotionally pivoting experience is cumbersome (Wortham, 2017). 

Sharing vantage-points with various psychological paradigms and theorems allows for an objective and holistic understanding of human factors that lead to predicatble error. By emphasizing that clinical error is typically a symptom of systemic flaw, cognitive dissonance may subside and allow honest reporting of mistakes.

If you have interest in learning more about the online university I decided to go with and pursuing a degree in Psychology, please reach out. Tylerchristifulli@gmail.com.

References:

Goodwin, C. J. (2015). A history of modern psychology (5th ed.). Hoboken, NJ: Wiley.

Klein, G. A. (1998). Sources of power: How people make decisions. Cambridge, Mass: MIT Press.

Redelmeier, D. A. (2005). The Cognitive Psychology of Missed Diagnoses. Annals of Internal Medicine, 142(2), 115. doi:10.7326/0003-4819-142-2-200501180-00010 

Wortham, S. (2017). Resistance and Psychoanalysis : Impossible Divisions. Edinburgh University Press