Addressing the basic science of medical decision making will require new ideas and true creativity. Your email address will not be published. Examples that employ heuristics include using trial and error, a rule of thumb or an educated guess. Understanding how we use them in medicine can help us improve practice. 2012 PAGES_12_AG_1006_BA.qxd:DCNS#52 10/03/12 12:46 Page 81 Shortcuts and heuristic reasoning may come into play under conditions of cognitive busyness, overload, noisy signals, fatigue, and resource limitations. Medical Example: An example of the Availability Heuristic in medicine is when a person overestimates the likelihood of complication based on the number and potency of stories shared by your social network and popular media. Representativeness involves jumping to an erroneous conclusion that is unlikely to be accurate, on the basis of an initial impression. Dr. Osterholm, Director of the Center for Infectious Disease Research and Policy, Dr. Murthy, Surgeon General, and Dr. Chen, Doctors For America, Dr. Sharpless, Director of the National Cancer Institute. 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. More Case Studies. If a vaccine causes an adverse effect in 0.1% of the population and you vaccinate one million people, 1000 people will have an adverse effect to that vaccination. Some are more general descriptions that encompass other more specific examples. 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. Despite best intentions, the influence of heuristics and bias find their way into clinical care. 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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.”. In short, these cognitive biases resulted in misdiagnoses and many malpractice lawsuits down the road. While buying lottery tickets because you read about lottery winners in the news is mostly innocuous, availability heuristic can have significant deleterious consequences in healthcare on both the patient and physician side. “The Availability Heuristic: Why Your Brain Confuses ‘Easy’ with ‘True.’” Kent Hendricks, 15 June 2018, https://kenthendricks.com/availability-heuristic/. 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. “The Availability Heuristic Is Ruining The Country.” Medium, 25 Jan. 2019, https://medium.com/betterism/the-availability-heuristic-is-ruining-the-country-74419403893b. These rare anecdotes become more available to parents than the horrors of the disease itself, which the vaccine has mostly eradicated and thus made less available. 48–51 In many medical settings, workload is dynamic, often varying unpredictably, and providers must select strategies to maintain throughput of patients. Merck Manual. In this lesson, you will learn to define the representativeness heuristic and apply it to real-world examples. This suggests that heuristics are established as capital cognitive problem-solving mechanisms at an early phase of cognitive development, at pre-university years. When you are trying to make a decision, you might quickly remember a number of relevant examples. 10, 01 2017, pp. Vaccines are one such prominent example as no vaccine is perfect: every vaccine carries some small risk of adverse events. Rapidly analyzing an ECG to diagnose a STEMI is one example. studies on non-medical students have yielded similar results. For example, if you are thinking of flying and suddenly think of a numb… The availability heuristic occurs when people make judgments about the importance of an issue, or the likelihood of an event, by the ease with which examples come to mind. A critical, ad hoc decision is made to call a “STEMI alert,” thereby activating the cath lab team and an interventional cardiologist. 330, no. “Communicating About Vaccines in a Fact-Resistant World.” JAMA Pediatrics, vol. The Mumps Measles and Rubella vaccination was reported to be linked to … What is the complexity level of the decision? Dyspnea and Back Pain in a 24-yr-old Man. The one-good-reason heuristic involves analyzing a short series of cues, then stopping when we perceive a strong or compelling cue. Cognitive psychologists may discover other heuristics, but medical research is unlikely to invent new ones. 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. Like a medical procedure, heuristics can have both risks and benefits. At what stage do you begin to form a preliminary judgement about the seriousness of the case? 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. Let’s start by exploring the good side. Kahneman and Tversky did a lot of work in this area and their paper “Judgement under Uncdertainty: Heuristic and Biases”  sheds light on this. 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. The one-good-reason heuristic involves analyzing a short series of cues, then stopping when we perceive a strong or compelling cue. What are your ideas for how to improve the use of heuristics in the practice of medicine? 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. There are two key domains where this kind of change could have a big impact. 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. But she also had a history of bypass surgery and multiple cardiovascular risk factors. After all, humans evolved to use heuristics long before modern medicine existed. 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. Don’t miss out on any of the latest blog posts. We should be able to teach these simple thinking processes overtly, just as we explicitly teach a one-hand tie to a surgical trainee. 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. For example, if it were an anonymous referral (and you know that many of these come from aggrieved neighbours), would your preliminary judgement be different? While heuristics are useful and cannot be avoided, we must be aware of potential biases and sources of error. For example, in a case of witnessed ventricular fibrillation (VF), immediate step of resuscitation and defibrillation is called for. 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. Cough in a 2-yr-old Boy. The availability heuristicinvolves making decisions based upon how easy it is to bring something to mind. Imagine a scenario where a patient presents with left leg pain and, upon examination, there is significant reddening and swelling of the leg. 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. This article shows how you can use heuristic evaluations to meet the regulatory requirements of usability engineering very quickly and economically. Trainees may subconsciously learn about heuristics through experience, but that method is slow and unreliable. Indeed, several studies with school pupils (2) have concluded that heuristics coincide with the emergence of formal reasoning 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. The availability heuristic is a mental shortcut defined by our being more likely to believe something based on how easily it comes to mind (i.e., how available it is). 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. But they can also lead to mistakes. 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. This post will review the common cognitive errors described in medicine. Representativeness heuristic is a cognitive bias. Heuristics, in general, have been evolutionarily ingrained in us because they represent mental shortcuts that are generally helpful for us to make quick and relatively accurate decisions about complex problems. John E. Brush, MD, is a practicing cardiologist and professor of medicine at Eastern Virginia Medical School. 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. 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. Cohen, Paul, and Nicholas Musisca. But we don’t." After weighing all the factors, we proceeded to the cath lab. For example, people have long believed that ulcers were caused by stress, due to the representativeness heuristic, when in fact bacteria cause ulcers. Becoming more aware of them and developing a common vocabulary will help us use them more effectively. 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. 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 … When discussing chronic, preventable conditions with the public, physicians should certainly root their findings and messaging in the data while also taking a page out of the politician handbook and using personal anecdotes that resonate more strongly with the audience. Medical Education 2009 The Power of Thinking Without Thinking . "The implicit assumption in medicine is that we know how to think. Seeing a pattern emerge from a patient’s historical narrative, leading to a diagnosis of chronic stable angina, is another. 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. Some common heuristics include the availability heuristic and the representativeness heuristic. Figure 1 A description of common biases encountered in clinical medicine and accompanying examples. "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. Required fields are marked *, Designed by Elegant Themes | Powered by WordPress. Heuristic Evaluation: Comparing Generic and Specific Usability Heuristics for Identification of Usability Problems in a Living Museum Mobile Guide App Meanwhile, in solving the ETP at Universiti Malaysia Pahang (UMP), Kahar and Kendall  presented a solution by using constructive heuristics , which was compared with a manual solution. Analyzing the validity of those commonly used cues may be one way to advance research about decision making in the field of medicine. Seeing a pattern emerge from a patient’s historical narrative, leading to a diagnosis of chronic stable angina, is another. A heuristic is a mental shortcut that allows an individual to make a decision, pass judgment, or solve a problem quickly and with minimal mental effort. 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. 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. Because heuristics simplify difficult decisions, they help us avoid “analysis paralysis” under conditions of uncertainty that demand speed. 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. In this process, it is quite easy to fall asunder by various cognitive biases, such as the availability heuristic. There are thousands of diseases and syndromes, but typically the number of reasonable choices is less than 10. Including more explicit training on the use of heuristics would undoubtedly improve the consistency and quality of medical decision making. How should we reconcile a view of good human decision-making using simple heuristics with the apparently straightforward picture of the superiority of algorithms? Ultimately however, the application of heuristics in clinical medicine is inevitable, particularly in emergency situations where every minute counts. To do it successfully, a player simply fixes his gaze on the ball and starts running. Loss of Consciousness in a 50-yr-old Man. 171, no. heuristics in medicine. 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. For example, when eggs are recalled due to a salmonella outbreak, someone might apply this simple solution and decide to avoid eggs altogether to prevent sickness. Binary—it's a strike or a ball. 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. Rapidly analyzing an ECG to diagnose a STEMI is one example. Strong cues may be a key detail from a patient’s medical history, a bead of sweat on the brow of a patient complaining of chest pain, or certain ECG findings. An initial ECG showing ST-segment elevation is, for example, a strong enough cue to prompt the immediate action of activating the cardiac cath lab. Representativenessrefers to estimating the likelihood of a diagnosis based on how well the patient fits the prototype for that condition. Issue. ECG findings of ST-segment elevation due to early repolarization could lead to the erroneous diagnosis of acute MI in a young patient for whom that diagnosis is very unlikely. 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. 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. Gigerenzer has identified an “adaptive toolbox” of heuristics that we commonly use to address various types of problems. 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 … However, perhaps this patient instead had necrotizing fasciitis (flesh-eating disease), which is much more dangerous than cellulitis and leads the patient to lose her leg because of your error. 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. The tallying heuristic allows us to organize cues in deciding among competing options. All rights reserved. Heuristics can be mental shortcuts that ease the cognitive load of making a decision. Since these are more readily available in your memory, you will likely judge these outcomes as being more common or frequently-occurring. You just need to know which ones to consider. Method: Data sources were original, peer-reviewed, empirical studies on cognitive biases and heuristics in medical decision making found in Ovid Medline, PsycINFO, and … Heuristic decision making in medicine - Marewski and Gigerenzer Dialogues in Clinical Neuroscience - V ol 14 . Omer, Saad B., et al. The role of cognitive biases and heuristics in medical decision making is of growing interest. Nonetheless, the cues that heuristics employ are domain-specific, with particular ones in each medical specialty and subspecialty. While this shortcut can often be innocuous in day-to-day-life, medicine leaves little room for the misjudgment arising from the availability heuristic. Used properly, this heuristic can turn you into an intuitive Bayesian thinker. For example, I talk about anchoring and adjusting to teach the proper use of stress testing. Hendricks, Kent. Posted by Simar Bajaj | Oct 25, 2020 | Medical Psychology | 0. The first heuristic mentioned is the Availability Heuristic. Stanford Antibiotics and Outpatient Infections CME Course. 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. heuristic: [noun] the study or practice of heuristic (see 1heuristic) procedure. In that case, how do you decide when ‘enough’ information consti… Given that typical presentations g… How well do we 2005, pp. Availability heuristic clearly plays out among patients, but physicians are not immune from this mental shortcut either. By concentrating only on the angle of gaze, he can ignore the speed, trajectory, and spin of the ball, as well as the wind and many other factors. You may subject the patient through unnecessary and potentially detrimental medical care because of the outsized importance you give to necrotizing fasciitis. Umpires Doctors. Heuristics provide strategies to scrutinise a limited number of signals and/or alternative choices in decision-making. Chest Pain in a 62-yr-old Man. An electrocardiogram reveals ST-segment elevation in 3 leads. 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. 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. You will notice that this list is not clean. Norman, Justin. Most physicians, whether trainees or seasoned clinicians, do not think consciously about heuristics. PubMed, doi:10.1001/jamapediatrics.2017.2219. 7494, Apr. Two common heuristics are Representativeness and Availability. This is an example of the ‘availability bias’ and a familiar scenario for those of us in clinical practice. The trick is to start by first analyzing the high-impact cues. On my teaching rounds, I often include a brief discussion of how we use heuristics in medical practice. 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. Anchoring and adjusting, a heuristic I discussed in my previous blog post, describes how we assess subjective probabilities starting with an initial (anchor) impression and then adjust the probability estimate by incorporating new information such as a test result. Research shows that simply tallying up unweighted cues is quite effective. To do it successfully, a player simply fixes his gaze on the ball and starts running. I also discuss the recognition heuristic to illustrate the value of taking a detailed narrative history from a patient — patient-reported cues emerge as a recognizable pattern, like stars in a constellation. Alternatively do you suspend all judgement until ‘all’ the relevant facts are known? For example, William Grove and his colleagues looked at 136 studies in medicine and psychiatry in which algorithms had been compared to expert judgement. Human cognition is a complex process. Psychologist Gerd Gigerenzer uses an analogy, called a “gaze heuristic,” of a baseball player catching a fly ball. 781–83. 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. 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. Join our mailing list to receive the latest news and updates from Doctor in Progress. If the story of necrotizing fasciitis or bacteraemia is more available, it can detrimentally impact physician’s diagnosis-making as they unjustifiably give weightage to the available diagnosis rather than the correct one.