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Bias in our Thinking
JAN BONE
CONSULTANT EMERGENCY PHYSICIAN
CHRISTCHURCH HOSPITAL
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Diagnostic Failure Risk Factors
▪Fatigue
▪Sleep deprivation
▪Cognitive overload
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Case
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Thinking about Chest Pain
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Case
Male, 65
▪ Central chest pain
▪ Onset 0200
▪ Retrosternal
▪ No radiation
▪ Worse on deep inspiration
▪ No SOB/collapse/palpitations
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Investigations
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Investigations
▪ hsTNT - 9 ng/L -> 10 ng/L
▪ WBC 15.7
▪ Hb 152
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Clues
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CTA
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Aortic Dissection
1. Uncommon -> 2-3/100,000/yr
(ACS = 400/100,000/yr)
2. Deadly - 1-2%/hr
Acute Type A mortality = 50% in the first 48 hours if not operated
90% 1 month mortality
3. Difficult to diagnose
it is ‘almost the standard of care to miss this diagnosis’
John Elefteriades (chief of CT surgery at Yale)
38% missed on initial evaluation
28% only diagnosed at autopsy
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Why do we make diagnostic errors?
• Availability
• Anchoring
• Confirmation Bias
• Premature Closure
• Representiveness Restraint
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How do we make a diagnosis
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How do we make a diagnosis
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How does aortic dissection present?
“Classical” Presentation is Atypical
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5 Tips to reduce your miss rate
Tip 1
Symptoms above and below the diaphragm
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5 Tips to reduce your miss rate
Tip 2
The “chest pain and….” syndrome
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5 Tips to reduce your miss rate
Tip 3
Acute, Severe, Unexplained chest pain
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5 Tips to reduce your miss rate
Tip 4
Young Abdominal Pain
+
Hypertension
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5 Tips to reduce your miss rate
Tip 5
The patient who “looks bad”
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D-dimer
▪ 220 patients with initial suspicion of having acute aortic dissection
▪ Sensitivity 96.6% (95% CI, 90.3 to 99.3)
▪ Specificity was 46.6% (95% CI, 37.9 to 55.5)
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Bedside USS
Image: http://echocardiographer.org/TTE.html
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Case resolution
▪ Rx:
▪ Fentanyl/Morphine
▪ Labetalol
▪ Transferred to Wellington
▪ Surgery same day
▪ Discharged 5 days post-op
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Summary
1. Chest pain = Aortic dissection
2. Don’t CT every chest pain patient!
3. Be aware of your cognitive biases and develop strategies to check them
4. Have insight into your thinking
▪ Chest pain = ?aortic dissection
▪ Collapse = ?aortic dissection
▪ Back pain = ?aortic dissection
▪ Symptoms above and below diaphragm = ?aortic dissection
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Diagnostic Processing
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How do we make a diagnosis
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Debiasing
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Successful Steps in Cognitive Debiasing
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Case 1
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Case 1
▪ 55 yr old male
▪ Constipation
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Case 2
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Case 2
▪ 19 yr old female
▪ Depression
▪ Anxiety
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Quality of Decision Making Influenced by
▪ Ambient conditions
▪ Individual factors
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High Risk for Bias Situations
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Other Cases
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Case 3
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▪ 23 yr old male
▪ Odd behaviour
▪ Never really fit in
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Case 4
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Case 5
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Case 6
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Case 7
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Summary
▪ Bias is common
▪ Types of processing
▪ Type 1 / Fast
▪ Type 2 / Slow
▪ High risk bias situations
▪ Debiasing techniques
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Case 8
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