Imagine the surgical theatre, a world of sharp precision where every decision carries the weight of a life. The faint hum of monitors merges with the subtle rustle of sterile gowns, creating an environment of intense focus. Yet, beneath the surface, unseen forces—cognitive biases—silently influence decisions, often tipping the scales towards error. This article explores the findings of a systematic review published in BJS (2023) by Bonnie A. Armstrong et al., shedding light on the pervasive impact of cognitive biases in surgery and the urgent need for mitigation strategies.
The Invisible Puppeteers: Cognitive Biases Defined
Cognitive biases, those sly distortions in our thinking, are like mischievous phantoms that whisper incorrect conclusions into a surgeon’s ear. Overconfidence bias stands tall, convincing surgeons of their superior skills even when evidence suggests otherwise. Anchoring bias, with its gravitational pull, locks their focus onto initial information, ignoring contradictory evidence. Confirmation bias, a loyal companion, validates preconceived notions, dismissing alternative possibilities.
The systematic review, encompassing 39 studies with over 6,514 surgeons and 200,000 patients, identified 31 distinct types of biases. Each bias, like a tiny cog in a malfunctioning machine, contributes to errors across preoperative, intraoperative, and postoperative phases. The stakes are monumental, as biases can culminate in adverse events, complications, or even death.
Themes of Impact: Unveiling the Patterns
The review unravelled six overarching themes where cognitive biases influence surgical performance:
- Inaccurate Risk–Benefit Estimations: Picture a surgeon weighing the risks and benefits of a complex procedure. Overconfidence whispers that success is guaranteed, while anchoring bias skews the risk assessment based on initial data. These biases cloud judgment, potentially leading to overtreatment or unnecessary diagnostic tests. In the chaotic symphony of the operating room, the tiniest miscalculation can amplify into a cacophony of complications.
- Inaccurate Perceptions of Ability: Overconfidence bias transforms self-assessment into a carnival mirror, distorting abilities. Surgeons may overestimate their skills, pressuring patients into procedures that offer little benefit. Imagine a surgeon standing at the crossroads, guided not by reality but by a flawed compass of self-perception.
- Variation in Risk Tolerance: Risk aversion and its counterpart, risk-seeking behaviour, are like temperamental artists shaping surgical decisions. A recent adverse event might instil excessive caution, leading to overtreatment. Conversely, familiarity with a procedure might encourage undue risk, exposing patients to avoidable harm.
- Neglecting Alternative Options: Anchoring and premature closure biases often blind surgeons to alternative diagnoses or treatments. Like a horse with blinkers, they charge ahead, tethered to initial assumptions. The result? Delayed diagnoses, unnecessary interventions, and missed opportunities for optimal care.
- Inconsistent Treatment Recommendations: Picture two surgeons facing identical cases. One opts for aggressive intervention, while the other chooses conservative management. Cognitive biases, particularly experience bias and risk aversion, often colour such inconsistencies, leaving patients at the mercy of subjective judgment.
- Other Impacts: From diagnostic momentum to omission bias, cognitive biases weave a web of errors that degrade surgical performance. These biases, though varied, converge on a singular outcome—reduced quality of care.
The Human Cost: Patient Outcomes at Stake
The review paints a vivid picture of patient harm linked to cognitive biases. Overconfidence and anchoring biases often manifest in surgical “never events”—unforgivable errors like operating on the wrong site. These biases also correlate with increased complications, delayed treatments, and, in severe cases, mortality. The findings highlight a grim reality: biases are not mere academic constructs but tangible threats to patient safety.
Uncharted Territory: Sources and Mitigation Strategies
While the review offers a treasure trove of insights, it also reveals glaring gaps. No studies empirically investigated the origins of cognitive biases, leaving their roots shrouded in mystery. However, some potential sources emerged, such as surgeon experience levels and systemic pressures like institutional demands for efficiency.
Mitigation strategies remain largely speculative. Education sessions to increase awareness of biases were the most commonly suggested interventions. Yet, awareness alone is a brittle shield against deeply ingrained cognitive patterns. The review advocates for systemic changes—nudges and decision aids designed to steer surgeons towards unbiased decisions. Imagine a surgical checklist infused with prompts to consider alternative diagnoses or review past complications, acting as a subtle yet effective guide.
The Path Forward: Bridging Gaps
The journey to mitigate cognitive biases in surgery demands a multi-pronged approach:
- Empirical Research: Future studies must delve into the origins of biases, exploring both person-based and system-based factors.
- Holistic Interventions: Combining education with systemic changes can create a robust framework to counter biases. For instance, “speak-up” campaigns can empower surgical teams to challenge assumptions, fostering a culture of collaborative decision-making.
- Technology Integration: Artificial intelligence and predictive analytics hold promise in identifying and mitigating biases. These tools can act as unbiased assistants, offering data-driven insights that transcend human limitations.
Conclusion: Beyond Awareness
Cognitive biases, like invisible strings, subtly manipulate surgical decisions. The systematic review lays bare their profound impact, transforming abstract concepts into concrete realities. Yet, the road to mitigation is long, requiring a symphony of research, innovation, and cultural change.
In the end, addressing cognitive biases is not merely about improving surgical outcomes. It is about honouring the trust patients place in their surgeons, ensuring that every decision—every scalpel stroke—is guided by clarity, precision, and an unwavering commitment to excellence.
Dr. Prahlada N.B
MBBS (JJMMC), MS (PGIMER, Chandigarh).
MBA in Healthcare & Hospital Management (BITS, Pilani),
Postgraduate Certificate in Technology Leadership and Innovation (MIT, USA)
Executive Programme in Strategic Management (IIM, Lucknow)
Senior Management Programme in Healthcare Management (IIM, Kozhikode)
Advanced Certificate in AI for Digital Health and Imaging Program (IISc, Bengaluru).
Senior Professor and former Head,
Department of ENT-Head & Neck Surgery, Skull Base Surgery, Cochlear Implant Surgery.
Basaveshwara Medical College & Hospital, Chitradurga, Karnataka, India.
My Vision: I don’t want to be a genius. I want to be a person with a bundle of experience.
My Mission: Help others achieve their life’s objectives in my presence or absence!
My Values: Creating value for others.
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Dear Dr. Prahlada N B Sir,
Your blog post, "Understanding Cognitive Bias in Surgical Practice," is a masterclass in shedding light on the unseen forces shaping surgical decisions. Your writing is precise, incisive, and illuminating, making complex concepts accessible.
I appreciate your emphasis on recognizing and mitigating cognitive biases, and the need for systemic changes. Your dedication to excellence in surgical practice and commitment to sharing knowledge are inspiring.
Thank you for sharing your insights. Your writing is a gift to the medical community.
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