Un-bias your brain to improve patient care

Use these strategies to look for and reduce cognitive error during patient assessment and care


By Benjamin Dowdy

Although much of our initial EMS training is focused on skills and learning didactic information about various illnesses and injuries, we quickly learn that critical thinking is one of the most important and toughest to learn skills that we perform. As we gain experience in assessing and managing patients, often in short time periods and challenging situations, we typically create our own mental shortcuts to provide care rapidly. These shortcuts, or heuristics, are often described as a defining characteristic of an experienced or master EMS practitioner; many times they work beautifully in assessing and treating patients efficiently and safely.

However, these heuristics aren’t infallible; they fail sometimes, leading to erroneous diagnosis and treatment. EMS providers certainly aren’t alone in this phenomenon; medical practitioners in every specialty, and especially emergency medicine, commit these diagnostic errors. The results of an incorrect diagnosis aren’t always immediately apparent, but they can be disastrous. As such, reducing cognitive errors in diagnosis have been an increasingly recognized and studied goal in health care.

Here are five ways we can begin to reduce cognitive errors in the delivery of EMS.

1. Know thine enemy
Anchoring, confirmation bias, premature closure, diagnosis momentum … the list of possible cognitive biases is long. Do some searching around to find types of cognitive biases and learn about how they impact decision-making.

Rather than trying to totally eliminate all biases from your thought processes, look at biases that lend themselves well to EMS. I focus on anchoring, premature closure, availability, and fundamental attribution errors. After you’ve gotten adept at looking for a few possible biases, add one or two more to the list and search for their presence. 

2. Use metacognition or thinking about thinking
Until you examine your thought processes, it’s difficult to identify cognitive biases because we’re typically not aware of them. Use a process called a cognitive autopsy to dissect your thinking after a call. Write down everything you can recall about a call; ambient conditions, when it occurred on your shift, things the patient said or did, the assessment findings, how they responded to your treatment.

After some time to rest, get in touch with the people who were at the call with you. Get their recollection of the call and compare notes. Were some things you recalled as fact actually perception or implied by your subconsciousness? This isn’t the same as the "How did that go?" hot wash immediately following a call. Cognitive autopsy is designed to evaluate thinking process, not performance.

3. Never stop gathering information
Too often EMS providers have a tendency to work through an assessment process until they’ve satisfied the requirements of one of their heuristics, then begin treatment based on that shortcut. While useful for beginning time-sensitive treatment early, this also introduces the possibility of multiple cognitive biases. Remember that assessment is a never-ending process. Keep gathering information and revise your list of possibilities, even if that means removing the diagnosis you originally thought was most likely.

4. Take short breaks during a call to reflect
Typically, as we encounter a patient we begin with a short list of possible diagnoses and use the information we gather to confirm or deny the possibilities on our list. This approach, while useful, can predispose us to anchoring and other cognitive biases. Part of this effect is known as cognitive overload

The prefrontal cortex of your brain responsible for these decisions has limited capability to multitask and can be overwhelmed, especially with patients who require immediate action or resuscitation. Take a short few seconds to pause and think about the information you’ve gathered. During these cognitive rally points ask yourself:

  • What’s likely?
  • What else could it be?
  • What diagnosis can I not afford to miss?

During these brief pauses allow time for your brain to catch up with the information you are gathering. This cognitive rally point is sometimes referred to as forced unbiasing.

5. Use memory aids to reduce cognitive overload
Algorithms, checklists and treatment bundles have utility in reducing the amount of actual thinking you have to do. While it sounds counterintuitive to recommend this in an article about thinking, not having to think about the next step in a protocol or algorithm frees your prefrontal cortex up and allows it to focus on what the underlying problem is.

ACLS algorithms are probably the most familiar example, but widely consider checklists for patient conditions like airway management, SIRS/sepsis, fibrinolytic checklists for STEMI/CVA. Checklists also work well as a forced cognitive unbiasing technique. If your patient in PEA hasn’t responded to CPR, ventilation with oxygen, and one round of a vasopressor, it’s probably time to step back and think of other causes.

There is a saying which is contrary to most EMT or paramedic classes, "Never memorize anything than can be written down."

Finally, remember that cognitive bias isn’t always the result of an individual. Feedback is a crucial part of identifying cognitive bias, metacognition and working to improve the quality of care we provide. Timely feedback from the ED physicians you deliver your patients to or your agency’s quality assurance department is a tremendous help, and such things as identifying cognitive bias and metacognition are integrated into periodic call review or QA/QI processes very easily. This may require additional efforts on the part of your QA department as well as the individual providers, but the fruits of those efforts are tremendous. Paying close attention to your heuristics and potential biases can open your eyes to the myriad of possibilities for bias, but also just how easy it can be to remove those biases.

Learn more
1. "Patient Safety in Emergency Medicine" by CroskerryP, et al, editors (ISBN-13: 978-0-7817-7727-B).

About the author
Ben Dowdy, B.S., NR-P, currently works in northern Idaho for a rural/frontier EMS system. His past experiences include work as a field provider, tactical paramedic, paramedic for the National Parks Service, and EMS educator.  He is a lead instructor for Wilderness Medical Associates, for whom he has taught medical courses for providers of all levels throughout the US as well as abroad.

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