The Federal Aviation Authority (FAA) are well-aware of the dangers of Plan Continuation Bias:
“The continuation of an original plan even with the availability of new information that suggests that the plan should be abandoned or at least updated.” AKA Get-There-Itis.
Get-There-Itis has been the cause of multiple fatal air-accidents, where pilots have allowed stressors to bias their decision making, and fatally stick to a failing plan. But… these stressors effect everyone and clinicians are not immune!
Predisposing Factors:
- Mission Imperative – Just get there
- Make the referral
- Clear the queue
- Complete the task
- Personal image
- Competent – Can you admit you don’t know OR question seniors? (you may look stupid)
- Confident – you’re better than average right? (only 50% of us are)
- Safe – does admitting you were wrong make you unsafe?
- Time pressure
- Your shift ends soon
- Lots more patients to see
- Resources – its natural to stick with a diagnosis that’s easy to treat/refer
- I can’t get that test
- Referring to that speciality is hardwork
- Health, relationships
- I leave my problems at home…?
Scenarios:
Get-There-Itis will have affected us ALL at various times, and we have ALL criticised others for it – Why Good Leaders Make Bad Decisions
- You only have 10mins before your shift ends, and the consultant asks you to see a patient with a straight forward plan.
- Would you risk being late home and looking stupid by questioning the consultant?
- A handover patient with a clear plan starts to deteriorate.
- You’re busy and they have a plan – follow that??
- Triage nurse tells you the patients here every day complaining of chest pain and needs to go home.
- You can’t be that good if you can’t discharge the patient???
Causes:
- Confirmation”, and “desirability” biases
- Seeing what we want to see – feels good.
- Questioning ourselves – is uncomfortable.
- Type 1 (reflex) thinking – it’s quicker, easier and feels better than Type 2 (computational) thinking.
- Over-estimating knowledge, skills, and experience
- ..clinicians…???
Prevention;
“When the facts change, I change my mind. What do you do, sir?” J.M. Keynes
- Treat a hypothesis
- ED is a best guess
- Admitting doubt allows you to change course
- Be willing to accept; new, better or disproving data
- Is the data agreeing for disagreeing with the proposed diagnosis?
- Is the treatment working…?
- Talk your problem through
- Emergency Medicine is a team sport – colleagues can recognise what you may have missed
- Recognize that any plan is immediately out of date and flawed.
- Have Plan A, B, C…… and let people know
- Use “all available information” to continually update (clinical and investigations)
- Recognise the pressures you’re under and how that’s affecting your thinking
- Expectations, time pressures, resource availability
Evidence: This works in the real world.
M. Christianson :Studied clinicians treating paediatric cardiac arrest, with faulty airway equipment (sims).
- Performance was highly variable.
- Fault recognission most frequently done by novices
- Effective updating most commonly had more experts on team
- Teams who found the fault were the ones who use most effective updating and listened to whole team
P. Tetlock: Studied the ability of individuals and groups (both professional and amateur) to predict movements in the financial markets
- Performance was highly variable.
- Amateurs often out performed professionals
- Good performance “Superforcasters” correlated with those willing to question their theories and assimilate new data.
