Even seasoned physicians can fall into cognitive bias traps

Take home message: By staying aware of cognitive biases and combining intuitive thinking with critical/analytical thinking as well as good history taking, physicians can improve quality of care.

By Vanessa Caceres; Reviewed by Harold E. Shaw, MD

Greenville, SC-Ophthalmologists naturally want to help patients to the best of their abilities and make accurate diagnoses.

Yet, even the most seasoned and knowledgeable ophthalmologist can fall victim to cognitive biases, said Harold E. Shaw, MD, Greenville, SC.

Both heuristics-which are mental shortcuts-as well as cognitive biases can sometimes negatively affect the way an ophthalmologist diagnoses a patient, Dr. Shaw said.

For example, one heuristic well-known in medicine is Occam’s razor, which basically states that for a patient’s given symptoms, they should look for one diagnosis instead of two. However, a counter well-known heuristic, Hickam’s dictum, states that a patient can “have as many diseases as they damn well please.”

Ophthalmologists (and physicians as a whole) can fall prey to a number of cognitive bias, including the following, Dr. Shaw said:

·      Anchoring: relying too heavily on earlier information and be overly influenced by a first impression

·      Premature closure: accepting a diagnosis before it has been fully verified

·      Availability: making a diagnosis based on what most readily comes to mind; the information that comes to mind quickly is based on recent or vivid experiences

·      Confirmation: giving more credence to information that supports what you believe instead of contradicting evidence

·      Framing: drawing different conclusions from the same information depending on how the information is presented.

“All of these are important because they influence our clinical decisions every day,” Dr. Shaw said.

Intuitive versus analytical

Ophthalmologists also should be aware of intuitive versus analytical thinking. Intuitive thinking is fast, automatic, and unconscious. Analytical thinking is slow, deliberate, and conscious.

“We often use intuitive thinking, which is efficient, but that’s where errors most often occur,” Dr. Shaw said.

Dr. Shaw shared a couple of cases in neuro-ophthalmology to make his point about thinking beyond the most obvious diagnosis.

For example, in one case, a 39-year-old man presented with mild headaches and blurry vision. He was evaluated for papilloedema in the right eye. The exam did not find papilloedema, but it did find optic nerve drusen. The patient’s abnormal visual field result may lead the neuro-ophthalmologist to think the cause is the optic nerve drusen, but further analysis actually found something indicative of a chiasm lesion. The patient was found to have a pituitary tumor.

“Sometimes, the obvious diagnosis may not be the most important,” he said. “When we hear hoofbeats, think about horses, but don’t forget about zebras.”

Harold E. Shaw, MD

E: halshaw@gmail.com

This article was adapted from Dr. Shaw’s presentation at Neuro-Ophthalmology Subspecialty Day during the 2015 meeting of the American Academy of Ophthalmology. He did not indicate any proprietary interest in the subject matter.