Ibrahim R, Haq M, Takamatsu C. Anchoring bias – a barrier to the art of healing. HPHR. 2021;53.10.54111/0001/AAA9
“Patient A” is a 25-year-old male with a history of type 1 diabetes mellitus complicated by presumed diabetic gastroparesis, who presents to the hospital with intractable nausea and vomiting. Upon first impression, the patient is agitated and hostile. “Patient A” is a poor historian, exhibiting limited medical insight and providing a contradictory history. A quick review of his chart details a longstanding history of drug abuse with multiple hospital visits in the last 2 years for similar presenting complaints of refractory vomiting totaling 15-20 episodes per day. “Patient A” is requesting medications to help with the burning discomfort associated with his nausea and vomiting; however, clinicians cautiously treat his pain due to his extensive history of substance abuse.
The current provider forgoes another comprehensive work-up, as his symptoms were previously investigated at prior presentations for the same complaints. A repeat hemoglobin A1C is deemed unnecessary because of known poorly-controlled diabetes. Additionally, further inquiry into the patient’s medical compliance is disregarded, given his chart previously classified him as a “non-compliant patient.” During hospitalization, “Patient A” is managed with strict glucose control, carbohydrate-controlled diet, antiemetics with gradual resolution of presenting symptoms, and repeated conversations emphasizing diabetic medical compliance which were poorly received by the patient.
However, for “Patient A”, it is an entirely different story.
He is once again a questioned captive in this sterile clinical environment. The unwelcoming cold hospital pillow against his cheek provides fleeting comfort, if any, after his 10th hospitalization for his very real symptoms, which are once again targets of disbelief and suspicion by his medical providers. He turns his head in an effort to shield himself from the blinding beams of fluorescent lights that burn his tired eyes as he is rolled past the familiar room numbers, guiding him to his new residence for the foreseeable days. He counts 211, 212, 213, and so on, attempting to escape the reality of his fourth hospital admission this month for his abdominal distress.
Rather than feeling reassured that maybe this will be the admission his care team discovers answers for and solutions to his ailments, he is disheartened and hopeless, feeling trapped in a futile cycle of symptomatic management of his complaints without anyone addressing the true cause of his issues. He is once again a doll for doctors, nurses, and medical technicians to ask the same repetitive questions, poke and probe at, and wake him up at all hours of the day to take his blood and measure his vitals with seemingly disregard for how he feels and what he wants. He wonders if anyone in this inhospitable place sees him as a real person with a life outside of these hospital walls, beyond his diseases and medical complaints; or is he simply just another undervalued patient in room 215 with this list of medical ailments everyone is attempting to patch with enough Band-Aids to conceal his problems, just enough to send him home again, knowing very well he will inevitably return with the same unresolved issues?
At this point, “Patient A” feels unheard and his medical literacy underappreciated. It seems everyone has forgotten his highly involved role in his medical care since his initial diagnosis of type 1 diabetes in childhood. No one recognizes his appreciation for the medical staff who provide him the insulin he needs, nor acknowledges that he adheres to the appropriate doses prescribed by his doctors and fully understands both the short- and long-term outcomes, as well as the complications, that come with his diabetes. Instead, his medical team focuses on his frequenting various hospitals over several months with uncontrollable nausea and vomiting. In despair, “Patient A” smokes marijuana to alleviate his ongoing symptoms.
“Patient A” is aware that his substance abuse history well documented throughout his electronic medical records influences the medical personnel who “care” for him. He does not feel well taken care of when there is a perceivable change in his interactions with doctors and nurses who suddenly become distrusting of his motives, disregarding his concerns. Their tone of conversation becomes skeptical, indicating to “Patient A” that he is once again trapped in a frustrating series of one-sided dialogues by medical providers, attributing his debilitating retching to diabetic gastroparesis. This inaccurate diagnosis provides medical professionals with the satisfaction of an answer but provides “Patient A” with no relief. Everyone who walks into his room unannounced is fixated on this incorrect diagnosis previously made by other providers. “Patient A” is desperate for a fresh perspective after he is yet again discharged home with the same diagnosis, plan, and educational material he tosses aside upon leaving.
After spending seemingly endless days in and out of hospital rooms over the past two years, feeling misperceived over and over again, “Patient A” eagerly seeks help at a new hospital. A provider with untainted eyes and a clear perspective performs a thoughtful, detailed evaluation. “Patient A” is commended for his efforts to achieve his goal hemoglobin A1C over the past year, serving as an active participant in his care to avoid complications of his disease, confirmed by normal peripheral neurovascular and funduscopic examinations. At last, this unbiased doctor miraculously provides “Patient A” with hope for an end to his crippling discomfort, the diagnosis of cannabinoid hyperemesis syndrome. Accordingly, he is advised to stop smoking marijuana, a substance that he once felt to be the only effective antiemetic when previous medical providers could not give him the help he sought. Following this recommendation, his symptoms completely resolve.
Why did it take years and endless hospital stays to reach the correct diagnosis? Unfortunately, this patient’s narrative is not unique to “Patient A.” It is attributable to a cognitive bias known as anchoring bias. An anchoring bias compels us to rely heavily on the first piece of information we have on a topic, thereby influencing our decisions that become rooted in a particular reference point or “anchor.” Viewing a patient through a lens distorted by these preconceived notions and judgments often leads to incorrect and/or delayed diagnoses.
While the obvious physical and financial harm to patients is concerning, what are the potentially everlasting long-term psychological consequences of these diagnostic delays? How can the trust of patient-provider relationships be repaired, if at all? This anchoring bias, compounded by the pressure of disagreeing with other providers’ analyses, results in a harmful, yet preventable, clinical outcome that needs conscious attention to mitigate undesirable consequences when caring for patients frequently utilizing healthcare resources for persistent physical symptoms. If not, this predisposes these patient populations to self-medicate with illicit and recreational substances when desperate for solutions not provided by their medical providers.
Implicit biases, which includes anchoring biases, are one of multiple causes that lead to major racial and socioeconomic healthcare disparities on a global scale.1-2 For example, a study completed in Switzerland found that healthcare providers in the German-speaking part of the country had skewed misconceptions regarding patients that were influenced by social factors including ethnicity and economic conditions of the patient.3 Another study completed in 2011 showed that markers of poor communication during a primary care visit were related to implicit race biases.4 Black patients in this study were more likely to be associated with poorer ratings of interpersonal care and lower patient positive affect when compared to White patients.
Greater physician awareness of these ethnic and socioeconomic biases and their implications in clinical care will enable clinicians to challenge these biases and work on their cultural sensitivity, patient-centered communication skills, and enhancing rapport with their patients. The first step in mitigating these disparities includes patient-centered communication given its positive correlation with greater patient trust and subsequently enhanced continuity of care and adherence to the medical plan.4-7 Patient-centered communications does not only include verbal communication but also entails nonverbal behaviors which often may lead to poor patient perceptions of the patient-physician interaction. This does include longer visit times, slower speech, enhanced speech fluency, and more smiling. In summary, these implicit biases are one of many manifestations of inequalities in healthcare today, and healthcare professionals should be expected to serve as influential advocates for their patients and for social justice.
The author has no relevant financial disclosures or conflicts of interest.
Ramzi Ibrahim is a first-year resident in the Internal Medicine Residency Program at the University of Arizona in Tucson, Arizona. He is an avid enthusiast of clinical applications for evidence-based medicine and is actively involved in medical education, as well as clinical research.
Maham Haq is a third-year medical student at Ross University School of Medicine and is currently completing her clinical rotations at the Mt. Sinai Hospital in Chicago, IL.
Chelsea Takamatsu is a second-year resident in the Internal Medicine Residency Program at the University of Arizona in Tucson, Arizona. She is an academic enthusiast who hopes to stay involved in medical education and peer mentoring throughout her career, as a future Chief Resident in her residency program.