How Provider Stress Can Lead to Cognitive Bias and Diagnostic Errors

Working in a high-stress environment like a children's hospital creates the perfect nesting place for cognitive bias, which comes from mental shortcuts used for quick decision making. That increases the risk of diagnostic errors. "When providers are under pressure, there's a tendency to default to a more rapid mode of decision making," says Ellis Arjmand, M.D., chief of Otolaryngology at Texas Children’s Hospital.

Consider the typical hospital environment: a busy clinic day, a full emergency department waiting room, half a dozen patients to round on. "We're forced to rely on shortcuts because they are time savers," Joe Grubenhoff, M.D. associate medical director of clinical effectiveness at Children’s Hospital Colorado, says. "Most of the time they get us to the right conclusions."

Anika Kumar, M.D., FAAP, pediatric hospitalist at Cleveland Clinic Children's Hospital in Ohio, agrees. "Burnout and fatigue make us rely heavily on our mental shortcuts," she says. "But they’re not always perfect. Nine times out of 10, we're right, but there's one chance that something's different than it appears."

Using shortcuts is a normal cognitive process; the risk is using this way of thinking at the wrong time. A surgeon once told Arjmand, "Do you know how many times I made a decision at 8:30 a.m. that’s different than the decision I made at 8:30 p.m.?"

Often, strategies to address the resulting errors or perceived performance issues don’t get at the underlying issue and create a sense of shame. "Providers often fear their knowledge base is being judged," says Grubenhoff. "If we can’t bring these issues out in the open and talk about them, we’re not going to move forward."