Shortcuts and heuristic reasoning may come into play under conditions of cognitive busyness, overload, noisy signals, fatigue, and resource limitations. For this article, we develop principles for how to improve the use of heuristics based on our own research in emergency medicine. 330, no. 48–51 In many medical settings, workload is dynamic, often varying unpredictably, and providers must select strategies to maintain throughput of patients. After all, humans evolved to use heuristics long before modern medicine existed. Statistics and data showing the vaccine is effective and safe are lost upon people because the availability heuristic makes them give greater weight and value to the anecdotes they hear. For example, during the winter months, clinicians experience an increase in the volume of patients experiencing flu like symptoms. In short, these cognitive biases resulted in misdiagnoses and many malpractice lawsuits down the road. Representativenessrefers to estimating the likelihood of a diagnosis based on how well the patient fits the prototype for that condition. That being said, the availability heuristic can also be used for more positive ends, specifically in the form of science communication and public health messaging. Posted by Simar Bajaj | Oct 25, 2020 | Medical Psychology | 0. But she also had a history of bypass surgery and multiple cardiovascular risk factors. Issue. Norman, Justin. An electrocardiogram reveals ST-segment elevation in 3 leads. Examples that employ heuristics include using trial and error, a rule of thumb or an educated guess. 7494, Apr. You may subject the patient through unnecessary and potentially detrimental medical care because of the outsized importance you give to necrotizing fasciitis. The one-good-reason heuristic involves analyzing a short series of cues, then stopping when we perceive a strong or compelling cue. The art of the diagnosis is a difficult task because physicians must discern from countless possible conditions the patient may have and come to exactly one diagnosis, the correct one. Dyspnea and Back Pain in a 24-yr-old Man. Indeed, several studies with school pupils (2) have concluded that heuristics coincide with the emergence of formal reasoning Representativeness involves jumping to an erroneous conclusion that is unlikely to be accurate, on the basis of an initial impression. Cellulitis is one of the most common bacterial skin infections and lines up with all the symptoms you see, so that is the diagnosis given. When you are trying to make a decision, you might quickly remember a number of relevant examples. “The Availability Heuristic: Why Your Brain Confuses ‘Easy’ with ‘True.’” Kent Hendricks, 15 June 2018, https://kenthendricks.com/availability-heuristic/. Because heuristics simplify difficult decisions, they help us avoid “analysis paralysis” under conditions of uncertainty that demand speed. By guarding against these tendencies, we can improve the chances that our heuristics — which, after all, are often useful — will yield good judgments. Nonetheless, the cues that heuristics employ are domain-specific, with particular ones in each medical specialty and subspecialty. Weak cues may be unreliable markers such as a soft carotid bruit or the lack of an S3 gallop. All rights reserved. The affect heuristic, for example, means if you like the doctor who is treating you, you’ll be more likely to follow their suggestions, putting less weight on the evidence of what consequences (positive and negative) this will have. A heuristicis a word from the Greek meaning “to discover.” It is an approach to problem solving that takes one’s personal experience into account. heuristics in medicine. What is the complexity level of the decision? The availability heuristicinvolves making decisions based upon how easy it is to bring something to mind. For example, in a case of witnessed ventricular fibrillation (VF), immediate step of resuscitation and defibrillation is called for. Trainees may subconsciously learn about heuristics through experience, but that method is slow and unreliable. Heuristic evaluation of medical devices Heuristic evaluation is a process which usability experts use to assess the usability of products by means of heuristics (explained in more detail below). I created this blog to help cultivate my passion for medicine, and I hope to inspire others to consider a career in medicine as well... Read More, Your email address will not be published. As the late Alvan Feinstein, the Yale educator and father of clinical epidemiology, once noted, “Every observant clinician has discovered that certain ‘short-cuts’ or other maneuvers, either of intellect or of action, can increase the efficiency of his work in clinical practice.”. Gigerenzer has identified an “adaptive toolbox” of heuristics that we commonly use to address various types of problems. However, the most stunning example was given to me by Dr. Kamal Singh, the chief of nuclear medicine and radiology at Kaiser Permanente, regarding one of his colleagues. Imagine a scenario where a patient presents with left leg pain and, upon examination, there is significant reddening and swelling of the leg. The first heuristic mentioned is the Availability Heuristic. Medical Education 2009 The Power of Thinking Without Thinking . A critical, ad hoc decision is made to call a “STEMI alert,” thereby activating the cath lab team and an interventional cardiologist. Research shows that simply tallying up unweighted cues is quite effective. In fact, the availability heuristic explains why politicians often use vivid anecdotes rather than facts and figures to make their points: they are banking on the fact that personal stories affect you more strongly than raw data. Required fields are marked *, Designed by Elegant Themes | Powered by WordPress. The purpose of this study was to determine whether studies on cognitive biases and heuristics in medical decision making are based on actual or hypothetical decisions and are conducted with populations that are representative of those who typically make the medical decision; to … But they can also lead to mistakes. NEJM Knowledge+ is a product of NEJM Group, a division of the Massachusetts Medical Society.Copyright © Massachusetts Medical Society. Psychologist Gerd Gigerenzer uses an analogy, called a “gaze heuristic,” of a baseball player catching a fly ball. Clinicians can be made more conscious of heuristics starting in medical school and continuing during fellowship training. Because these pictures of people going out are most available to you (as nobody posts about staying home to study), you are likely to have a warped perception of how everyone is spending their Friday night. You just need to know which ones to consider. My name is Simar Bajaj, and I am a college student at Harvard University. The chance that a plane crashes is dependent on a huge number of factors, such as wind speed, the model of the plane, the pilot, etc., all of which are difficult to estimate or even consider for that matter. If he maintains a constant angle of gaze by adjusting the direction and speed of his running, he will arrive at just the right spot to make the catch. Given this context of the availability heuristic in everyday circumstances, we can now return to the availability heuristic in medicine, specifically examining how it affects patient decision-making. Since these are more readily available in your memory, you will likely judge these outcomes as being more common or frequently-occurring. Heuristics can be mental shortcuts that ease the cognitive load of making a decision. The trusted provider of medical information since 1899. To do it successfully, a player simply fixes his gaze on the ball and starts running. The medical adage “when you hear hoof beats, consider that it is a horse not a zebra” helps us avoid this trap. You will notice that this list is not clean. Strategies, such as considering if data is relevant than just salient, playing devil’s advocate with yourself, and looking at the issue quantitatively with base rates, can all help to overcome availability heuristic. For example, the likelihood of renal colic is deemed higher in the patient with sudden-onset intractable flank pain than in the patient with insidious mid-back pain. What we do have readily available, however, is the anecdotal experiences and stories we have heard, which is why we overestimate the chance of plane crashes. Certainly, whenever a vaccine is introduced for a disease, the number of new cases for that disease will fall; however, as more and more people are vaccinated, the number of adverse events will certainly rise. The following is an example of a patient diagnosed with breast cancer presented at a multidisciplinary tumor board that demonstrates the way in which bias can be introduced even in well-intended care settings. In that case, how do you decide when ‘enough’ information consti… Analyzing the validity of those commonly used cues may be one way to advance research about decision making in the field of medicine. Human cognition is a complex process. Kahneman and Tversky did a lot of work in this area and their paper “Judgement under Uncdertainty: Heuristic and Biases”  sheds light on this. Join our mailing list to receive the latest news and updates from Doctor in Progress. Binary—it's a strike or a ball. Psychologists Daniel Kahneman and Amos Tversky studied many of the pitfalls of heuristics, such as these: The base-rate neglect fallacy, explored in my previous post, surfaces when we misuse the anchoring and adjusting heuristic. Most physicians, whether trainees or seasoned clinicians, do not think consciously about heuristics. These adverse events become horror stories that parents recount to one another, ultimately making them, and those they tell these stories to, less likely to get their children vaccinated in the future. While this shortcut can often be innocuous in day-to-day-life, medicine leaves little room for the misjudgment arising from the availability heuristic. availability heuristic: A nonsystematic form of reasoning based on how easily a solution to a problem is encountered in thought rather than in logic or careful analysis. Representativeness heuristic is a cognitive bias. How should we reconcile a view of good human decision-making using simple heuristics with the apparently straightforward picture of the superiority of algorithms? Cohen, Paul, and Nicholas Musisca. Similarly, you likely believe that you are more likely to be in a plane crash than in a car crash because plane crashes make huge news (e.g., Malaysian Airlines Flight 370 and 9/11) even though the chance of dying in a plane crash is 862 times less likely than dying in a car crash. Figure 1 A description of common biases encountered in clinical medicine and accompanying examples. We should be able to teach these simple thinking processes overtly, just as we explicitly teach a one-hand tie to a surgical trainee. Heuristic decision making in medicine - Marewski and Gigerenzer Dialogues in Clinical Neuroscience - V ol 14 . Groopman's article focuses on the role played by heuristics in medicine, but his thesis is applicable in any field of endeavor; Croskerry could have said, "The implicit assumption in … For example, if you want to catch a fast-moving, high looping ball, you don't need to solve complex differential equations, consciously or unconsciously. Cognitive psychologists may discover other heuristics, but medical research is unlikely to invent new ones. In that way, they can improve decision-making effectiveness. The Availability heuristic is based on the ease of which certain examples or events come to mind, in this case, in the , mind of the clinician. Merck Manual. Vaccines are one such prominent example as no vaccine is perfect: every vaccine carries some small risk of adverse events. Availability is a pitfall in which judgment is clouded by salient or recent events that happen to be more available and accessible to our working memory and intuition. "Availability heuristic" allows a person to judge a situation on the basis of the examples of similar situations that come to mind, allowing a person to extrapolate to the situation in which they find themselves. Cough in a 2-yr-old Boy. 781–83. For example, William Grove and his colleagues looked at 136 studies in medicine and psychiatry in which algorithms had been compared to expert judgement. This article shows how you can use heuristic evaluations to meet the regulatory requirements of usability engineering very quickly and economically. For example, I talk about anchoring and adjusting to teach the proper use of stress testing. Addressing the basic science of medical decision making will require new ideas and true creativity. In a similar line of thinking, in some alternative medicine beliefs patients have been encouraged to eat organ meat that corresponds to their medical disorder. Stanford Antibiotics and Outpatient Infections CME Course. You are a social worker on duty in an intake team and you receive a child protection referral from a local doctor. After weighing all the factors, we proceeded to the cath lab. The Mumps Measles and Rubella vaccination was reported to be linked to … Hendricks, Kent. There are two key domains where this kind of change could have a big impact. While this mistake deserves attention in its own right, the anecdote you now have of your failing to diagnose necrotizing fasciitis may lead you to needlessly harp on this diagnosis for future patients even when all the evidence points away from it. Here are a few: The recognition heuristic enables us to use a single cue or a recognizable pattern of cues to quickly form a conclusion or size up a situation. This is an example of the ‘availability bias’ and a familiar scenario for those of us in clinical practice. PubMed, doi:10.1001/jamapediatrics.2017.2219. Expert clinicians know how to filter out weak cues and focus on strong cues, as if separating signal from noise. Rapidly analyzing an ECG to diagnose a STEMI is one example. In the ER, I recently saw a patient with chest pain and a history of gastroesophageal reflux, which she had hoped was the cause of her pain. Stories that we experience or hear about second-hand affect us much more strongly than research or data that is several degrees of separation apart. Method: Data sources were original, peer-reviewed, empirical studies on cognitive biases and heuristics in medical decision making found in Ovid Medline, PsycINFO, and … Umpires Doctors. For example, people have long believed that ulcers were caused by stress, due to the representativeness heuristic, when in fact bacteria cause ulcers. These cognitive shortcuts are also known as heuristics. Heuristics diminish the work of retrieving and storing information in memory; streamlining the decision making process by reducing the amount of integrated information necessary in making the choice or passing judgment. Imagine that you are spending your Friday night studying in your dorm room, studying for a big midterm you have that week. Vaccines are one such prominent example as no vaccine is perfect: every vaccine carries some small risk of adverse events. For example, when discussing lung cancer and the dangers of smoking, while the fact that 90% of all lung cancer cases are caused by cigarette smoking is relevant, giving an anecdote of a father who smoked a pack a day for several years, tragically got diagnosed with Stage IV lung cancer, and died shortly thereafter may be more impactful as public health messaging. heuristic: [noun] the study or practice of heuristic (see 1heuristic) procedure. Editor’s Note: This post about decision-making shortcuts was previously published in CardioExchange, an online community hosted by the New England Journal of Medicine and NEJM Journal Watch. Missing an uncommon diagnosis such as aortic dissection can be very troubling and memorable, but we should not then give this possible diagnosis undue weight in assessing subsequent patients. Heuristics provide strategies to scrutinise a limited number of signals and/or alternative choices in decision-making. She had two critical lesions and received two stents, and her pain resolved. You take a break and peruse Instagram, seeing countless examples of your classmates going out and having a great time, causing you to feel horrible about yourself and how you are spending your time at college. 2005, pp. Seeing a pattern emerge from a patient’s historical narrative, leading to a diagnosis of chronic stable angina, is another. 171, no. 929–30. Seeing a pattern emerge from a patient’s historical narrative, leading to a diagnosis of chronic stable angina, is another. At what stage do you begin to form a preliminary judgement about the seriousness of the case? For example, if you are thinking of flying and suddenly think of a numb… I created this blog to help cultivate my passion for medicine, and I hope to inspire others to consider a career in medicine as well. Given that typical presentations g… Before we consider the availability heuristic within medicine, understanding how the availability heuristic plays out in everyday contexts proves helpful. Background. Availability heuristic clearly plays out among patients, but physicians are not immune from this mental shortcut either. To do it successfully, a player simply fixes his gaze on the ball and starts running.