Cognitive biases and their effects on practice: a case study reflection
Abstract
Clinical decision-making is a key aspect of the student paramedic journey. In particular, it is vital that students can understand the theories that underpin this vital facet of their practice. This article considers a case encountered in practice and the evidence that informs the decision process which was undertaken. The influence of biases, systems of thinking and an appreciation of probability are all considered in this call to a 55-year-old patient with chest pain. In addition, an appreciation of robust history taking is considered as part of this process. As ambulance clinicians can be limited in the tests and scoring systems appropriate to them, consideration is given to the value of traditional ‘in-hospital’ scoring systems and the advantages and limitations they present to the paramedic. These limitations can ultimately result in hospital attendance in many acute presentations such as chest pain incidents, and it may be that our practice is overdue a review of what can be done to address such limitations.
This clinical case study involved a 55-year-old woman who called 999 for severe central chest pain that radiated to her left arm and neck. The patient had an extensive medical history including a previous myocardial infarction (MI), bipolar disorder, anxiety and depression, as well as a complex social history.
Initially, I was unaware that the patient was a frequent caller. However, while en route to the patient, I was informed that there had been 15 ambulance attendances this month, most commonly with a presenting complaint of severe central chest pain.
Obtaining this information initiated an anchoring bias that influenced my clinical decision-making (Collen, 2017). Anchoring bias commonly occurs because a clinician relies heavily on initial information provided, then fails to consider additional information (Rutherford, 2020). This could occur if alternative factors, including vital signs and electrocardiogram (ECG) interpretation, as well as providing holistic patient centred care are dismissed. This can potentially lead to a misdiagnosis from interpreting the presentation as the patient's usual one. This was evident within this case study as the initial focus was on the fact that the patient frequently presented in this way, rather than on considering alternative differentials to determine a diagnosis.
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