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.