American Academy of Emergency Medicine

"That's So Meta": Cognitive Bias

Kudos to MS4 Calderone. It's encouraging to see someone so early in his/her career realize our "science" is hindered or enhanced by our own personal psychology. I encourage her and other young physicians to continue to delve into this subject as it belies the arguments of medical malpractice. Our profession would be well-served if she, and others like her, took upon themselves, as part of their career, to educate his/her fellow physicians and, more importantly, the general public about the nuances of the clinical decision-making process. It is important for society to understand that medicine is not an algebraic equation. For better or worse, our past experiences play a starring role in our thinking process. Two reasonable physicians can start with the same set of facts and reach different conclusions. Not because one is smarter and the other one is careless. But because our clinical decision-making process cannot be divorced from our humanity.

Hector Peniston Feliciano, MD FAAEM

Thanks for your letter. I agree. That's why I encourage all physicians who act as expert witnesses to remember two things above all else. 1) Be aware of your own hindsight bias when you evaluate a case. When you know in advance the pt eventually suffered a posterior circulation stroke, what looked like peripheral vertigo to the original physician was "obviously" a vertebrobasilar TIA. If the pt had no diplopia or other cranial nerve deficits, however, calling that negligent means you are saying that every pt with vertigo must have a CT angiogram or MRA of the head and neck before being sent home. Be fair, and think about where your chain of reasoning will end up. 2) Remember what "standard of care" and "negligent" actually mean. The standard of care is not perfection, what you do in your practice, or what they do where you trained. It is reasonable care. Negligence is something a "reasonable" physician would not have done under similar circumstances. "Reasonable" includes a broad range of medical choices and actions, many of which you might not have chosen. Unfortunately a tiny fraction of physicians will say anything if paid well enough for their testimony. Most plaintiff's experts, however, are sincere and well-intentioned -- but blinded by their own hindsight bias or misunderstanding of what constitutes negligence in emergency medicine.

Andy Walker, MD FAAEM

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