Think back to a time when you found yourself in an Emergency Department, either as a patient or with family or friends. Depending on the city and the time of day, you most likely found yourself among many other patients waiting long hours in the waiting room with varying levels of maladies. After finally getting rushed back to a room you most likely were briefly assessed by an ED clinician and, if you were stable, treated and quickly sent home. If you have been several times, you know that almost always your assessment in the back of the emergency department is significantly shorter in duration than your wait in the waiting room. This is unfortunately the nature of an ER.
Ed clinicians work in an environment that demands speed and efficiency. They are required to see a large volume of patients as quickly as possible and in the case of a deteriorating patient, must make decisions almost instantaneously. The ever increasing amount of patients in the waiting room only adds to necessity of efficiency. In such circumstances, the use of heuristics can be both valuable and deadly.
This entry in the Journal of Physician Assistant Education describes common heuristics utilized in the Emergency Department. The first heuristic mentioned is the Availability Heuristic. 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. For example, during the winter months, clinicians experience an increase in the volume of patients experiencing flu like symptoms. After seeing so many each day, sometimes all in a row, it is understandable that the clinician becomes more likely to consider influenza as a diagnosis in their next patient with similar symptoms. This heuristic is helpful in the fact that it allows clinicians to quickly diagnose patients which eventually leads to them seeing more patients overall in a given amount of time. It can be harmful however, if a patient presenting with flu like symptoms during flu season, in fact is ill with some other disease. This heuristic would make the clinician more prone to misdiagnosing such a patient.
The next heuristic described in the article is the Representative heuristic. This heuristic occurs when a person is judged based on a characteristic or feature that is attributed to an entire group. For example, if a clinician believes young adults are more prone to anxiety then they may attribute the patient’s symptoms of chest pain and shortness of breath to anxiety because they fall into the group of “young adults.” While anxiety may be the cause of these symptoms in some patients it is not necessarily the cause in all “young adult” patients which would lead to a misdiagnosis.
The final topic mentioned is the Fundamental Attribution Error in which the failure or success of someone is attributed to who that person is as opposed to environmental factors that may be at play. In the world of emergency medicine, this would be evident when a patient’s chief complaint is considered to be their own fault. Of course, in some situations, a patient finds themselves in the emergency room as a result of their own actions and it is indeed their fault. However the Fundamental Attribution Error is at play when a patient, such as an obese patient, is complaining of symptoms that are automatically attributed to that patient’s weight. The journal article proceeds to give an example of this by saying that a “skinny” patient complaining of shortness of breath and leg pain will be evaluated differently than an obese patient complaining of the same things because the symptoms are automatically attributed to the obese patients weight. Obviously this could also lead to errors in diagnoses as well.
Overall, I agree with the article and believe it did a good job explaining the availability and representative heuristics in the context of an emergency department. I also believe it did a good job describing the Fundamental Attribution error however I am not so convinced by its example regarding the “skinny vs obese” patients. From a medical standpoint, it would be logical to evaluate a healthy patient complaining of a symptom uncommon for healthy patients, differently than an obese patient complaining of symptoms often linked to obesity. This is because each patient would have different risk factors and would therefore need to be considered in different contexts. Not all patients can be considered the same.
While heuristics may be beneficial in the emergency department, they can also be detrimental. It is clear that all clinicians should be aware of their tendencies towards these mental shortcuts so misdiagnoses that could result can be avoided. Working as a scribe in an emergency department, I have often found that I too utilize these heuristics when trying to determine the possible causes of a patient’s chief complaint. After seeing a certain pattern of symptoms and patient presentations lead to the same diagnosis over and over again, it is difficult to not draw that conclusion again when evaluating a similar patient. In accordance with the availability heuristic, I often find myself considering the most severe diagnoses I have seen when being presented with patients with similar symptoms simply because these are the diagnoses I remember the best and most easily. From my experience volunteering as a EMT, it is my suspicion that these heuristics extend to other providers in the field of medicine such a prehospital providers like EMTs and Paramedics. These providers must also make quick decisions based on very little information while treating patients. Education in metacognition would most likely be beneficial to providers in almost all fields of medicine.