In this lesson, you will learn to define the representativeness heuristic and apply it to real-world examples. Background. The role of cognitive biases and heuristics in medical decision making is of growing interest. 1 . 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. 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. 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? The tallying heuristic allows us to organize cues in deciding among competing options. 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. However, while heuristics … Vaccines are one such prominent example as no vaccine is perfect: every vaccine carries some small risk of adverse events. Research shows that simply tallying up unweighted cues is quite effective. 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. Chest Pain in a 62-yr-old Man. Psychologist Gerd Gigerenzer uses an analogy, called a “gaze heuristic,” of a baseball player catching a fly ball. By guarding against these tendencies, we can improve the chances that our heuristics — which, after all, are often useful — will yield good judgments. For example, I talk about anchoring and adjusting to teach the proper use of stress testing. But she also had a history of bypass surgery and multiple cardiovascular risk factors. Heuristic decision making in medicine - Marewski and Gigerenzer Dialogues in Clinical Neuroscience - V ol 14 . Trainees may subconsciously learn about heuristics through experience, but that method is slow and unreliable. In that case, how do you decide when ‘enough’ information consti… In effect, less is better. 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. Professional Version. Syncope in an 80-yr-old Woman. Representativenessrefers to estimating the likelihood of a diagnosis based on how well the patient fits the prototype for that condition. For this article, we develop principles for how to improve the use of heuristics based on our own research in emergency medicine. 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. Indeed, several studies with school pupils (2) have concluded that heuristics coincide with the emergence of formal reasoning 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 … Method: Data sources were original, peer-reviewed, empirical studies on cognitive biases and heuristics in medical decision making found in Ovid Medline, PsycINFO, and … studies on non-medical students have yielded similar results. There are two key domains where this kind of change could have a big impact. Alternatively do you suspend all judgement until ‘all’ the relevant facts are known? What are your ideas for how to improve the use of heuristics in the practice of medicine? In short, these cognitive biases resulted in misdiagnoses and many malpractice lawsuits down the road. 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. 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. This post will review the common cognitive errors described in medicine. Analyzing the validity of those commonly used cues may be one way to advance research about decision making in the field of medicine. For example, people have long believed that ulcers were caused by stress, due to the representativeness heuristic, when in fact bacteria cause ulcers. 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. This is an example of the ‘availability bias’ and a familiar scenario for those of us in clinical practice. Rapidly analyzing an ECG to diagnose a STEMI is one example. 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. Representativeness involves jumping to an erroneous conclusion that is unlikely to be accurate, on the basis of an initial impression. But we don’t." Many of the biases overlap. After all, humans evolved to use heuristics long before modern medicine existed. Loss of Consciousness in a 50-yr-old Man. In that way, they can improve decision-making effectiveness. 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. While heuristics are useful and cannot be avoided, we must be aware of potential biases and sources of error. Addressing the basic science of medical decision making will require new ideas and true creativity. Given that typical presentations g… The medical adage “when you hear hoof beats, consider that it is a horse not a zebra” helps us avoid this trap. 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. 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. These cognitive shortcuts are also known as heuristics. 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. 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. Umpires Doctors. Binary—it's a strike or a ball. Gigerenzer has identified an “adaptive toolbox” of heuristics that we commonly use to address various types of problems. Don’t miss out on any of the latest blog posts. Heuristics provide strategies to scrutinise a limited number of signals and/or alternative choices in decision-making. Nonetheless, the cues that heuristics employ are domain-specific, with particular ones in each medical specialty and subspecialty. The Mumps Measles and Rubella vaccination was reported to be linked to … 2012 PAGES_12_AG_1006_BA.qxd:DCNS#52 10/03/12 12:46 Page 81 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. 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. Used properly, this heuristic can turn you into an intuitive Bayesian thinker. NEJM Knowledge+ is a product of NEJM Group, a division of the Massachusetts Medical Society.Copyright © Massachusetts Medical Society. 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). Norman, Justin. Paper on Narrative Communication for Changing Health Behaviors. heuristic: [noun] the study or practice of heuristic (see 1heuristic) procedure. 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. Before we consider the availability heuristic within medicine, understanding how the availability heuristic plays out in everyday contexts proves helpful. The trusted provider of medical information since 1899. Understanding how we use them in medicine can help us improve practice. Issue. Join our mailing list to receive the latest news and updates from Doctor in Progress. 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. 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. On my teaching rounds, I often include a brief discussion of how we use heuristics in medical practice. Examples that employ heuristics include using trial and error, a rule of thumb or an educated guess. A critical, ad hoc decision is made to call a “STEMI alert,” thereby activating the cath lab team and an interventional cardiologist. 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. 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. The one-good-reason heuristic involves analyzing a short series of cues, then stopping when we perceive a strong or compelling cue. Figure 1 A description of common biases encountered in clinical medicine and accompanying examples. A patient comes to the ER complaining of 2 hours of substernal chest pain. 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. 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. 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.”. 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. Imagine a scenario where a patient presents with left leg pain and, upon examination, there is significant reddening and swelling of the leg. Rapidly analyzing an ECG to diagnose a STEMI is one example. 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. 330, no. "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. 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. 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. Some are more general descriptions that encompass other more specific examples. 10, 01 2017, pp. All rights reserved. Psychologist Gerd Gigerenzer uses an analogy, called a “gaze heuristic,” of a baseball player catching a fly ball. 2005, pp. Ultimately however, the application of heuristics in clinical medicine is inevitable, particularly in emergency situations where every minute counts. Cognitive psychologists may discover other heuristics, but medical research is unlikely to invent new ones. 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. “How Do We Misdiagnose and Mismanage Necrotizing Fasciitis?” EmDOCs.Net – Emergency Medicine Education, 16 Oct. 2017, http://www.emdocs.net/misdiagnose-mismanage-necrotizing-fasciitis/. 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. 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. Despite best intentions, the influence of heuristics and bias find their way into clinical care. Hendricks, Kent. Medical Education 2009 The Power of Thinking Without Thinking . How should we reconcile a view of good human decision-making using simple heuristics with the apparently straightforward picture of the superiority of algorithms? 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. 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. For example, during the winter months, clinicians experience an increase in the volume of patients experiencing flu like symptoms. For example, William Grove and his colleagues looked at 136 studies in medicine and psychiatry in which algorithms had been compared to expert judgement. Posted by Simar Bajaj | Oct 25, 2020 | Medical Psychology | 0. What is the complexity level of the decision? My name is Simar Bajaj, and I am a college student at Harvard University. My name is Simar Bajaj, and I am a college student at Harvard University. 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. There are thousands of diseases and syndromes, but typically the number of reasonable choices is less than 10. The trick is to start by first analyzing the high-impact cues. This suggests that heuristics are established as capital cognitive problem-solving mechanisms at an early phase of cognitive development, at pre-university years. Most physicians, whether trainees or seasoned clinicians, do not think consciously about heuristics. To do it successfully, a player simply fixes his gaze on the ball and starts running. “Communicating About Vaccines in a Fact-Resistant World.” JAMA Pediatrics, vol. Dyspnea and Back Pain in a 24-yr-old Man. Cough in a 2-yr-old Boy. 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. Some common heuristics include the availability heuristic and the representativeness heuristic. No. 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. Stanford Antibiotics and Outpatient Infections CME Course. 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. Shortcuts and heuristic reasoning may come into play under conditions of cognitive busyness, overload, noisy signals, fatigue, and resource limitations. You just need to know which ones to consider. 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. Imagine that you are spending your Friday night studying in your dorm room, studying for a big midterm you have that week. Cohen, Paul, and Nicholas Musisca. An electrocardiogram reveals ST-segment elevation in 3 leads. At what stage do you begin to form a preliminary judgement about the seriousness of the case? We spend most of our life with fewer than 150 people, so most of what we know comes from examples from our day-to-day life. 781–83. 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). You will notice that this list is not clean. Clinicians can be made more conscious of heuristics starting in medical school and continuing during fellowship training. 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. Two common heuristics are Representativeness and Availability. Weak cues may be unreliable markers such as a soft carotid bruit or the lack of an S3 gallop. 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. Ultimately, we all have a responsibility to actively combat cognitive biases and shortcuts in our decision-making because our failure to do so in healthcare in particular costs lives. 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. 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. After weighing all the factors, we proceeded to the cath lab. Availability heuristic clearly plays out among patients, but physicians are not immune from this mental shortcut either. Let’s start by exploring the good side. The availability heuristicinvolves making decisions based upon how easy it is to bring something to mind. Klein, Jill G. “Five Pitfalls in Decisions about Diagnosis and Prescribing.” BMJ : British Medical Journal, vol. You are a social worker on duty in an intake team and you receive a child protection referral from a local doctor. For example, if you are thinking of flying and suddenly think of a numb… Your email address will not be published. 929–30. For example, in a case of witnessed ventricular fibrillation (VF), immediate step of resuscitation and defibrillation is called for. "The implicit assumption in medicine is that we know how to think.
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