Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

A Tale of Two Stents


We are all vulnerable to cognitive biases. The clinically excellent clinician takes time to slow down and steps back when working toward the definitive diagnosis.

We are vulnerable to cognitive biases as physicians. Biases can walk in tandem with implicit biases that inexorably shape our thinking. Add compressed time to the mix and the clinician may fail to recognize and see what our patients need recognized and seen.


Slow down, take time outs—think, “What else could this be?”


I’ll be sharing two vignettes, with permission (identities and some details are changed.) Both involve rapid thinking, stretched foci of attention, and unanticipated clinical events.


First vignette:

I was seeing my last patient in a morning session and was 45 minutes behind. As I was finishing up, I noticed another patient’s e-mail and a second message on my desk phone.


I needed to finish up with the patient in front of me, but it was odd I had a message in two places.


I called back, holding up my patient in the exam room. It was a 72-year-old man with remote prediabetes (never converting as he got his BMI to 23 long ago), mild hyperlipidemia on a low potency statin, chronic bronchiectasis, and reflux. I had known him for 15 years as a patient.


Patient: Doctor C, I feel better now, but when I woke this morning I had a discomfort in my left neck and I oddly felt sweaty. That’s all gone for a few hours now, I think I’m fine. But I don’t have my appetite.


The patient has a medical background, and had remained home because his “symptoms passed.” He was struck by his stomach discomfort, and by his hunger being off, as was I.


“I think I’m ok, I’ll keep you posted,” he said.


Me: Do you realize there’s some chance that it’s your heart? You don’t have a lot of risk factors, but let’s have some humility about the one thing that can hurt you. I’d like you to get to the ER now.


This is phone medicine and triage during a compressed time of a patient session. Happens all the time.


He hesitated, but relented.


In the ER, he was hemodynamically stable, but ST wave elevations were present—tall ones in his inferior wall. He had big troponins. My patient was in the catheterization suite in a few minutes and an RCA stent was placed 45 minutes later.


Second vignette:

I was thirty minutes behind during a morning session. There’s a knock on the door as I’m in the exam room with a patient. It’s our fabulous nurses triaging calls.


Nurse: Dr. C, one of your patients, Ms. S—she’s called with some bad abdominal upset. She reports it as an ache in the pit of her stomach.


I come out of patient’s room—I turn back to my patient, “Excuse me for just a second.”


I felt a little angst creep in.


Fast thinking—doxycycline can be so hard on the stomach . . . I didn’t want to fall more behind . . .


Inner dialogue—this must be the doxy turning her stomach upside down.


I tell the nurses, “have her pick up some ranitidine, have some TUMS, and have her take the next doxycycline after a large meal.”


I go back to the rest of the morning’s patients.


At home, Ms. S’s pain crescendoed and became unbearable. She went to the ER herself.  There she was hemodynamically stable, and still in pain. She had vascular risk factors, a woman told to pick up some ranitidine. The ECG showed inferior wall ST elevations, tall ones. Troponins were big. She was whisked to the cath lab and stented 45 minutes later.


What WAS my clinical reasoning as I processed those intra-session messages from other patients?


I had it right in the elderly man. Fewer risk factors. The symptoms at the time of the call were not that “typical” (probably a word that should be stricken from chest pain evaluations.)


I was way off in the woman. I anchored on so much.


I anchored on the Lyme, the doxycycline, and the narrative that doxycycline bothers the stomach in many patients. I did not let the same humility in. She had risks for sure. Inferior wall ischemia and infarcts give gastric symptoms all day long, I know that.


The availability bias, the “within case” momentum bias, the hint of overconfidence, the fast confirmatory dialogue that only entertained a convenient interpretation.


I’m a PGY24, I engaged in all of it. My heuristics helped the patient in one case, almost hurt the other.  I’ve been told by others it was “not a miss.”


But I have another larger worry. The implicit bias that screws physicians up, plain and simple, when it comes to CAD/MI in women—I think somewhere in my rushed metacognition it was there.


Here’s what I learned:



1.Slow down and take a step back. Take a breath.



2.Spend some time thinking.



 3.If part of the story doesn’t fit, think what else it could be.



Remember the forces that frame, name all of the biases aloud as you’re working patients up, consider illness scripts, and form more complete differentials.


Both patients are doing well, and Ms. S gave up her cigarettes!