Heuristics: A probable element in medical errors

by Dr Benjamin Cheah
Updated February 3, 2014


Crossair Flight LX498 crashed in January 2000 minutes after takeoff. Investigations later revealed that the captain was taking a benzodiazepine drug which may have resulted in him misinterpreting his attitude indicator (gyroscope). Under stress, he resorted to his prior experience as a Russian pilot which had different attitude indicators on their aircrafts. Instead of the artificial horizon moving in western aircrafts, the miniature airplane would move indicating the pitch, bank and roll of the airplane. This led the captain to think that his aircraft was banking left when it was actually the reverse and the resulting incorrect recovery measure.

A learning method called heuristics is a common method used to simplify difficult cognitive tasks especially under stress. It refers to experience-based techniques for problem solving, learning, and discovery that give a solution which is not guaranteed to be optimal. For an experienced pilot to make this error, it is certainly conceivable that doctors do it too in medicine.

Heuristics is an important thought process in medicine especially in simplifying medical decision making. However, it can lead to wrong decisions when the crunch comes. Two types of heuristics come to mind ; availability and representativeness heuristics. Availability heuristic is a mental shortcut that occurs when people make judgments about the probability of events by the ease with which examples come to mind, while representativeness heuristic is a mental shortcut used when making judgments about the probability of an event under uncertainty or, judging a situation based on how similar the prospects are to the prototypes the person holds in his or her mind.

While most medical decisions are consciously made with intimate knowledge of the evidence, there are countless times during periods of stress that the thought process takes a major shortcut, which may result in medical errors. How about the number of doctors performing with medications that can impair that thought process further?

Perhaps it is the pscyhologists and neuro scientists that can help shed light on this subject, which I fear is prevalent in medicine leading to medical errors. One way of preventing such errors could be to allow adequate rest for doctors and to ensure that in an emergency situation, several levels of doctors are called upon to verify earlier decisions and the measures taken to address them.

It also illustrates how important clinical training is in the early stages of a doctor’s life. During periods of stress, they fall back to an almost primitive instinct involving their earlier experiences, which may not be correct as demonstrated in the above case scenario involving a very experienced pilot. This phenomenon cannot be ignored and similar to the airline protocol, junior officers should be allowed to challenge the decisions of their more “experienced” superiors. Doctors on duty should also not be taking prescription medications or under the influence of alcohol. I fear that this aspect is neither stressed upon nor given due attention.

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