The introduction is also posted on Spotify as a podcast by “Gerry at The Health Equation”
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Gerry Gajadharsingh writes
“In clinical practice, everything is about something else. Symptoms are rarely just symptoms; histories are never neutral; and the way a story is first told often matters as much as the data that follows. Long before investigations are ordered or differential diagnoses refined, a subtle but powerful process has already begun: the shaping of a clinician’s thinking by the very first information placed in front of them.
This is not a moral failing, nor a reflection of poor intelligence or inadequate training. It is human cognition at work. Modern medicine likes to imagine itself as objective, linear, and relentlessly evidence-led, yet the reality of day-to-day clinical practice is far messier. We listen, we pattern-recognise, we prioritise—and in doing so, we anchor. A single early detail offered by a patient, embedded in a referral letter, or highlighted during triage can quietly set the trajectory of the entire diagnostic process, often without the clinician’s conscious awareness.
A recent article highlighted by Medscape brings this issue into sharp focus. It reminds us that a substantial proportion of diagnostic error does not arise from ignorance or lack of knowledge, but from how information is filtered, framed, and prematurely fixed. If we are serious about improving diagnostic accuracy, patient safety, and professional humility, we must be willing to examine not just what we think, but how we come to think it—and how easily that process can be biased from the very first sentence.
Cognitive Bias and Diagnostic Error
It is estimated that up to 75% of errors in internal medicine have a cognitive origin. In other words, nearly three-quarters of medical errors are linked not to missing data or technical incompetence, but to flaws in clinical reasoning itself. Against this backdrop, experts increasingly emphasise that recognising, naming, and teaching cognitive biases is essential to improving medical practice.
Among the most common cognitive biases encountered in clinical work are anchoring bias, availability bias, and confirmation bias. Each can subtly—but decisively—shape diagnostic judgement, often operating below the threshold of awareness.
Anchoring bias occurs when a clinician relies too heavily on the first piece of information received—the “anchor”—when forming a judgement, while minimising or disregarding later, and often more relevant, data. Once established, this initial impression can influence subsequent assessments, investigations, and treatment decisions, particularly when the original anchor is incorrect.
Availability bias refers to the tendency to base decisions on information that is most recent, vivid, or easily recalled, rather than on what is statistically or clinically most relevant. A recently encountered diagnosis, dramatic case, or memorable outcome can disproportionately influence future reasoning.
Confirmation bias describes the inclination to seek out, favour, or overvalue information that supports an initial diagnostic hypothesis, while downplaying or dismissing evidence that suggests alternative explanations.
When the First Clue Sets the Course
A recent study provides a particularly clear illustration of anchoring bias in action. The research involved 54 practising physicians within the Spanish healthcare system, including both general practitioners and neurologists. Participants were presented with a clinical vignette in one of two versions.
In one version, the patient explicitly expressed concern about a specific serious disease. In the other, no such suspicion was mentioned. Apart from this single difference, the clinical information was identical. After reading the vignette, physicians were asked to identify the most likely diagnosis and indicate which diagnostic tests they would request.
The findings were striking. The initial information provided to the physician—the patient’s expressed concern—significantly influenced diagnostic decisions. When a serious disease was mentioned early, clinicians were far more likely to anchor on that possibility and direct their diagnostic reasoning accordingly. This occurred despite the availability of additional, potentially more relevant information later in the vignette.
These results are consistent with previous research showing that clinicians tend to privilege their first impression, even when more precise or contradictory data becomes available. In effect, the initial clue becomes the lens through which all subsequent information is interpreted.
Interestingly, medical specialty emerged as a relevant factor. When an anchoring signal was present, specialists were more likely than general practitioners to follow it closely. The authors suggest that this may reflect differences in clinical approach: specialists, drawing on deep experience within a narrower domain, may rely more heavily on cognitive shortcuts that increase efficiency but also vulnerability to anchoring.
Implications for Training and Practice
The implications are profound. Cognitive biases affect all clinicians, regardless of sex, level of experience, or seniority. Notably, the study found no strong evidence that clinical experience protects against anchoring bias. Expertise may refine intuition, but it does not immunise against flawed reasoning.
This reinforces the need for both educational and organisational strategies to address cognitive bias throughout a clinician’s career. Training in reflective clinical reasoning, deliberate slowing-down of decision-making, and the routine use of verification strategies can all help. Simple but powerful tools—such as diagnostic checklists or the disciplined question, “What else could this be?”—force a re-examination of assumptions in light of evolving information.
Ultimately, good clinical practice requires more than knowledge and technical skill. It demands ongoing awareness of how easily our thinking can be shaped by context, language, and sequence. If everything in clinical practice is indeed about something else, then learning to recognise those “something elses” may be one of the most important diagnostic skills we can cultivate.”
Clinical Disclaimer
This article is intended for educational and informational purposes only. It does not constitute medical advice and should not replace individual consultation with a qualified healthcare professional.
First Patient Details Can Bias a Doctor’s Diagnosis
Medscape
Laura Clavijo Villagrasa
Up to 75% of errors in internal medicine have a cognitive origin, meaning that nearly three quarters of medical errors are linked to flaws in clinical reasoning.
Against this backdrop, experts emphasised in a recent study that recognising and teaching about cognitive biases is essential to improving medical practice.
Among the most common cognitive biases encountered in clinical practice are anchoring bias, availability bias, and confirmation bias. Each can subtly but decisively shape diagnostic judgement, often without the clinician’s awareness.
Common Biases
Anchoring bias occurs when a clinician relies excessively on the first piece of information received (ie, the anchor) when forming a judgement, while minimising or ignoring later and more relevant data. This first impression can influence subsequent assessments and treatments, particularly when the original anchor is incorrect.
Availability bias involves basing decisions on information that is most recent or most easily retrieved in the physician’s memory, not on the most clinically relevant information.
Confirmation bias refers to the tendency to seek out or preferentially value data that support an initial diagnostic hypothesis, while dismissing evidence that suggests alternative diagnoses.
A recent study confirmed the influence of anchoring bias on diagnostic decision-making among both general practitioners and specialists. The study included 54 practising physicians from the Spanish healthcare system, including primary care physicians and neurologists.
Participants were presented with a clinical vignette that was randomly assigned in one of two versions. In one version, the patient explicitly expressed concern about a specific serious disease. In the other, no particular suspicion was mentioned. After reading the vignette, physicians were asked to indicate the most likely diagnosis and which diagnostic tests they would request.
The only difference between the two vignettes was this initial piece of information, which was designed to assess the anchoring effect on clinical decisions.
The authors of the study noted that the nature of the information provided to the physician significantly influences diagnostic decisions. Specifically, the first information communicated by the patient, whether or not a serious suspicion is mentioned, largely determines the final diagnosis, which is consistent with the anchoring bias described in the literature.
This finding is consistent with the results from previous research showing that healthcare professionals tend to base decisions on their initial impression, even when more precise or relevant information becomes available later.
The authors concluded that the patient’s initial clue anchor themselves to it and direct their diagnosis toward that disease more frequently than those who evaluate the same case without such a clue.
Medical specialty emerges as a relevant factor in how initial information is processed. According to the study, when an anchoring signal is present, specialists tend to follow it more closely than general practitioners.
The authors suggested that this may be explained, at least in part, by differences in clinical approach. The tendency of specialists to rely on cognitive shortcuts developed through experience could make them more prone to anchoring on their initial impression.
The findings highlight the importance of addressing cognitive biases during medical training and in routine clinical practice. Strategies such as training in reflective clinical reasoning and the use of verification protocols, including diagnostic checklists or the systematic question “What else could it be?” force clinicians to reassess their hypotheses in light of new information.
The study also found that a physician’s sex does not influence the likelihood of anchoring on an initial diagnostic impression, suggesting that interventions should be directed at all clinicians equally. In addition, there was no strong evidence that clinical experience protects against anchoring bias. This reinforces the need for educational and organisational measures for both physicians in training and experienced practitioners.