CLINICAL COMMUNICATION TO THE EDITOR
Anchors Away: A Case of Apparent
Sinusitis
To the Editor:
Diagnostic errors, dened as failures to reach timely and
accurate explanations for a patients presentation, affect the
majority of our patients, because most will experience at
least one diagnostic error in their lifetime.1 We report the
case of a patient who was inappropriately diagnosed with
acute bacterial rhinosinusitis and later found to have lym-
phoma. We use this case as a paradigm for introducing the
role that diagnostic errors and cognitive biases play in
clinical care, and discuss strategies for minimizing them.
A 72-year-old woman with no signicant medical history
presented to the hospital with a rapidly enlarging neck mass.
Four months earlier, she was seen at an urgent care clinic
with otalgia and hearing loss, and the diagnosis of acute
bacterial rhinosinusitis was made. Her symptoms persisted
despite antibiotic therapy, and over the next 4 months, she
was treated with 3 additional antibiotic courses. She then
noticed left-sided facial fullness, prompting presentation to
the hospital. Biopsy conrmed the diagnosis of lymphoma,
and further imaging showed diffuse disease. Her disease
was refractory to multiple chemotherapy regimens, although
she is now receiving immunomodulatory therapy with
improvement in disease burden.
A better understanding of the diagnostic process can help
minimize errors such as those made in this case. The diag-
nostic process relies on patient-, systems-, and clinician-
related factors. The clinician-related factors include
aspects such as knowledge base and the reasoning process,
the latter of which is susceptible to cognitive biases.
We identify several cognitive biases that likely played a
role in this case. Premature closure, or the acceptance of a
diagnosis before its verication, was likely implicated,
because the patient was diagnosed with acute bacterial
rhinosinusitis despite the lack of cardinal features such as
fever or facial pain. Because of availability bias, which is
Funding: None.
Conict of Interest: None.
Authorship: Both authors had access to the data and played a role in
writing this manuscript.
Requests for reprints should be addressed to Ritika S. Parris, MD,
Department of Medicine, Beth Israel Deaconess Medical Center, Deaconess
Building Suite 306, One Deaconess Rd., Boston, MA 02215.
E-mail address: rparris@bidmc.harvard.edu
0002-9343/$ -see front matter 2016 Elsevier Inc. All rights reserved.
the error of making diagnoses on the basis of recent
experience, providers are less likely to consider diagnoses
that are less prevalent in their practice.1,2 Certainly, acute
bacterial rhinosinusitis is more commonly encountered
than lymphoma at urgent care centers. In addition,
anchoring, or the maintenance of ones initial diagnosis
despite new ndings, may explain the prescription of
multiple antibiotic courses without reevaluation of the
diagnosis in a timely fashion.1,2
Identifying cognitive biases requires a better under-
standing of the reasoning process. This process can be
categorized as system 1 or system 2 thinking, also known as
fast and slow, respectively.3 System 1 thinking is quick,
relying on pattern recognition, heuristics, and prior experi-
ences. Meanwhile, system 2 is analytic, deliberate, and
time-consuming, involving techniques such as hypothesis
generation and diagnostic modication.1 Both methods play
key roles; using system 2 thinking alone would be taxing
and unsustainable in our high-volume health care system,
whereas system 1 thinking may be more error prone.
Therefore, it is important to determine the appropriate uses
for each strategy, optimizing efciency and accuracy.
Just as switching to system 2 thinking in certain clinical
situations is a debiasing technique, other strategies include
A Correct B Incorrect
diagnosis diagnosis
Feedback
Recalibrate
C All
diagnoses
No feedback
Figure Critical role of feedback in clinical reasoning. (A)
Feedback reinforces decisions that lead to correct diagnoses
and (B) allows for recalibration when necessary. (C) In the
absence of feedback, clinicians may continue inappropriately
on a default pathway.
e66
metacognition, deliberate consideration of alternatives, and
feedback and calibration.2,4 Appropriate feedback on clinical
decisions helps amplify the reasoning that leads to correct
diagnoses (Figure A) and allows for an opportunity for
calibration when an incorrect diagnosis is made (Figure B).
However, if no feedback is provided to the clinician, then
the reasoning process continues on the default trajectory,
regardless of the accuracy of the diagnosis (Figure C).
In our increasingly complex health care system, increased
attention to diagnostic and cognitive errors is required. Our
case serves as a lesson in several strategies that can be used to
reach a more timely and accurate diagnosis.
Ritika S. Parris, MD
Alexander R. Carbo, MD
The American Journal of Medicine, Vol 130, No 2, February 2017
Department of Medicine
Beth Israel Deaconess Medical Center
Boston, Mass
http://dx.doi.org/10.1016/j.amjmed.2016.09.013
References
1. National Academies of Sciences, Engineering, and Medicine. 2015.
Improving Diagnosis in Health Care. Washington, DC: The National
Academies Press; 2015. Available at: http://dx.doi.org/10.17226/21794.
Accessed August 12, 2016.
2. Croskerry P. The importance of cognitive errors in diagnosis and stra-
tegies to minimize them. Acad Med. 2003;78:775-780.
3. Kahneman D. Thinking, Fast and Slow. New York, NY: Farrar, Straus,
and Giroux; 2011.
4. Croskerry P. The feedback sanction. Acad Emerg Med. 2000;7:1232-1238.