CONTEXTUALIZING THE USE OF HEURISTICS AND BIASES: FAILING TO 'SLOW DOWN WHEN YOU SHOULD' IN SURGICAL PRACTICE

Background:  Heuristics are short-cut, automatic mental strategies that usually lead to appropriate judgments with greater efficiency than analytical methods. However, they are also a source of error because of associated cognitive biases. A recently identified phenomenon - ‘slowing down when you should’ - describes the transition from the automatic to effortful mode when confronted by uncertainty. An exploration of this phenomenon in surgical practice raised factors that complicate the assumption that a given heuristic is the primary source or explanation for error. The purpose of this study is to identify and classify psychosocial factors for surgeon error and to explore their influences on the use of heuristics in practice.

Methods:  This grounded theory study is guided by a literature review of existing error classification systems and identified heuristics and biases. This study comprises two phases – interviews and observations – with each phase informing the other. The study is currently in Phase I, and consisted of a number of completed semi-structured surgeon interviews focusing on perceived causes of failures to slow down and the use of heuristics and cognitive biases as they relate to surgeon error. The study used an iterative design, with data collection and analysis occurring concurrently. Purposive and theoretical sampling strategies were used and a reflexive approach was adopted throughout.

Results:  Preliminary analysis from Phase I produced a conceptual framework for understanding the psychosocial factors associated with failing to slow down in surgical practice. Situational factors e.g., time pressure, external distractions, and fatigue limit cognitive resources, and promote the use of ‘short-cuts’ or heuristics. Ego, confidence, and perceived social pressures were individual characteristics which can influence cognitive biases. Within the surgical culture and the pressures implicit within it, overconfidence and ego may deter a surgeon from thoroughly considering alternatives and instead search for information that will reject discrepancy and uncertainty in unexpected situations, resulting in confirmation bias.

Conclusion: Awareness of the factors that influence surgeons' judgment and decision making make more obvious the interactions that exist between situational, cultural, social and psychological factors of surgeon error. Considering them in isolation ignores the complexity of clinical practice and therefore potentially simplifies the solutions to minimizing surgeon error in practice. In Phase II, the preliminary framework constructed in Phase I will be refined through observations and interviews with surgeons during real-time events in their clinical environments.