The anchoring heuristic error in clinical decision making
Every clinical interaction requires healthcare professionals to make reasoned clinical decisions about the treatments they perform and the recommendations they make. Evidence informed and defensible decisions need to be based on appropriate findings and current understanding of pain and biopsychosocial processes.
Cognitive bias affects much of our clinical reasoning and decision making. The best way to overcome our biases is to be mindful of them. Acknowledging our biases helps us to maintain an open mind and encourages critical thinking. Being ignorant of your bias or resistant to science will never allow you to grow personally or professionally.
I recently encountered a term which is perfect at explaining what too often happens to therapists. A common cognitive bias that I feel affects many of us in our clinical work is the anchoring heuristic error. This is the common human tendency to rely too heavily on the first piece of information offered (the “anchor“) when making decisions. During decision making, anchoring occurs when individuals use an initial piece of information to make subsequent judgments. Once an anchor is set, other judgments are made by adjusting away from that anchor. Bias occurs when you interpret subsequent information around the anchor.
An heuristic is a problem solving approach used to accelerate the process of finding a satisfactory solution. It is a mental shortcut that eases cognitive load when making decisions. It is a good guess often not made with strong reasoning. If time were taken to reflect on the information presented one would likely come to a different decision.
An example of this bias in the healthcare environment.
When presented with information, the practitioner focuses on the first piece of information attained. Subsequent information has little effect on altering that initial impression. Questioning, assessment, interventions, prognosis and exercise are all adjusted from the initial information, the anchor. This is an all too common occurrence in the rehabilitation world, the inability to think outside of our comfort zone. Why is it the first thing the patient says to us is what we focus on, when there may be more relevant and important information that could help us with our reasoning and decision making processes?
How often are patients treated for something that is of minimal clinical relevance? Anecdotally, in my clinical practice there is rarely a day that passes where people in pain have been given well intentioned but poorly reasoned care. The unfortunate consequence is the patient, who ends up suffering longer than necessary because of ineffective and unnecessary interventions. My assumption, this is a result of pathoanatomical and structural based ideologies of pain and dysfunction that are held by the majority of healthcare professionals. Fortunately, gradual changes in the thinking and framework is occurring. Unfortunately, this change is slow.
Another example is basing treatments from medical imaging. In the absence of any severe dysfunctions or red flags, medical imaging is highly unhelpful at determining prognosis for most painful complaints. When presented with findings from medical imaging, most are innocuous. We treat the person, not a picture! How these findings are interpreted by the practitioner and presented to the patient can have massive consequences for their general well-being and rehabilitation process. If your anchor is the image, and your heuristic is making an educated guess without proper reasoning, than the treatments you perform and/or recommend may be incomplete as you have fallen into a bias that needs to be resolved in order to make reasoned decisions that serve the patient’s best interests.
Be mindful of your biases. After each challenging interaction practice self-reflection. Take a few minutes to think about the clinical encounter and analyze what you did well and what could you do differently. Incorporate reading research as part of your practice. If possible, connect with others on social media. They will challenge your beliefs and make you a better therapist.
Remember, there are often many ways to approach a problem. A single intervention is rarely a quick fix for a complicated problem. As healthcare providers it is our ethical duty to stay informed and strive to provide the best care possible. Question, listen, discuss. Be comfortable making mistakes, because that is where you will gain your most knowledge.