During a typical afternoon, you have a cramped schedule with 8 to 9 patients to see during a 3-hour clinic. Your pager buzzes many times, in between these clinic encounters about another patient receiving chemotherapy under your care. The stage is set you to make a decision for your patient without thinking too much. Alternatively, you may rely too heavily on the information provided by another physician, which is (un)popularly known as “anchoring bias.”

An elderly woman was evaluated for new-onset strabismus. A magnetic resonance imaging (MRI) scan of her brain revealed a petrous-caval area lesion, which was reported to be a meningioma based on its radiographic appearance. She also reported worsening back pain. An MRI of her spine revealed a L4 lytic lesion. A biopsy of the vertebral lesion revealed findings of a plasmacytoma—an extramedullary version of monoclonal plasma cell neoplasm that is not related to meningioma in the oncology pedigree.

Initially, I was inclined to accept the radiological diagnosis as it was. After all, it was a busy day like any other and my decisions had to be made in the blink of the eye. However, I was unable to eliminate the ever-nagging question in my head: “What if...?”

After deliberating with the patient about the pros and cons, we decided to obtain a biopsy of the intracranial mass. Ironically, this biopsy revealed a plasmacytoma. This was important. It changed our management plan from focal radiation to the hip and spine for the solitary plasmacytoma to, instead, systemic therapy for multiple plasmacytomas and systemic disease. The long-term benefits have yet to be determined, but we hope and believe that our lastminute dramatic intervention allowed us to make the right decision for the patient.

At first, I didn’t think there was a reason to share this case. However, I was later inspired to share my story after attending a morbidity and mortality case conference during which the case mentioned below (case 2) was discussed.

A middle-aged man was evaluated for a metastatic melanoma located in the lung. The man’s brain scan revealed a lesion that was, incidentally, deemed to be a meningioma based on his radiology report. But was it? This time, a lack of time to consider the man’s options for diagnosis got the better of the clinician’s judgment.

The decision was made to start systemic therapy for melanoma while following the brain lesion, as would be done for a meningioma. As we know, intracranial metastasis from melanoma warrants radiation or surgical intervention. Nevertheless, treatment for melanoma was initiated with immunotherapy, a treatment consideration given former President Jimmy Carter’s case. As we have learned, the median time to treatment response is roughly 3 months with immunotherapy.

As oncologists, we don’t get many shots at being right. After a couple of weeks, the patient developed a change in mental status, which turned out to be secondary to increasing size of the brain lesion and worsening edema surrounding it. Upon surgical resection and microscopic evaluation at this time, the brain lesion was found to be metastatic melanoma, which was then managed with postoperative radiation in addition to systemic therapy.

After initially being signed out of the emergency department by his physician as having meningitis, as suggested by a high fever, tachycardia, headaches, and tremors, a patient was admitted to the medicine floor for further care. An additional elaborate patient history, obtained by a medical student on the hospital floor, revealed that the patient had a history of hyperthyroidism. The patient also mentioned that he had not taken his medication for the condition in a while. Fortunately, the medical student was neither shy nor slow to speak up. Based on the results of additional workup, a hyperthyroid crisis was diagnosed, which could have become potentially fatal if not recognized in time and managed appropriately.

Anchoring bias refers to a cognitive tendency to lock on to a clinical diagnosis too early, often by making decisions based on information provided by another physician. It’s the tendency to fit the symptom complex into the diagnosis box and anchor onto a diagnosis already provided to us.

Historically, anchoring bias was first conceptualized by professors Amos Tversky, PhD, and Daniel Kahneman, PhD. Anchoring bias is an issue not only recognized by physicians in healthcare, but also in other professions and even in our daily lives. Over the years, psychologists have tried to put together various theories describing the mechanism of this occurrence.2 Regardless of how it happens, it can potentially be catastrophic, although rarely so.

We all fall prey to it. After all, it’s convenient! Having said that, we can’t undermine the external factors that play a role in the execution of clinical errors (fatigue, stress, the distraction of a buzzing pager, supporting services such as laboratory data, system pressures to expedite discharges, etc). In a world where medicine is practiced in a more commercial manner, the ticking clock with every patient encounter only reinforces the possibility for errors in judgment.

It also is important to understand, as a trainee, that believing information already cooked and served to us can hamper critical thinking and kill the spirit of academic inquiry. It adversely affects what we try to seek, every moment of our professional lives—quality of patient care. It leads to clinical error, that “never-forgiven mistake” in medicine. Although anchoring bias may bring a transient sense of reward for being able to explain the story, it offers no long-term glory.

I have described several examples of how this fast and frugal approach could have dire and loathed consequences. It would be unjust and incomplete of me to end this article without sharing a few tips for addressing anchoring bias that I have learned through personal experience.

The first step to solving a problem is realizing that a problem does, in fact, exist. Although most physicians acknowledge that errors occur, they may not recall a diagnostic error of their own. Being cognizant of the fact that we are human and that pursuing a deeper understanding never hurts; it is a general tendency we are all expected to have been inculcated with. When juggling multiple medical complaints, which may or may not be relevant to a patient’s cancer or acute medical issue, it is imperative to separate out all relevant information.

When reviewing a case, I suggest taking some time to develop a mental list of things it “could be” and consider each possibility with an open mind. Following from the decree from French National Convention, which promoted “great responsibility follows inseparably from great power,” the importance of differential diagnosis can also be considered inseparable from the actual final diagnosis.

 I also suggest seeking insight from colleagues. Team members, whether junior or senior, can all play an integral role when making decisions about diagnosis and treatment. It’s not only helpful to us (as trainees), but encouraging as well, to keep an open mind when running through different variables. Nevertheless, there are, and will always be, unmodifiable factors that will influence our decisions. Therefore, we should accept them, identify them, and shout out to a colleague when appropriate.

Robert C, Ribas A, Wolchok JD, et al. Anti-programmeddeath-receptor-1 treatment with pembrolizumab in ipilimumabrefractory advanced melanoma: a randomised dose-comparison cohort of a phase 1 trial. 

 2014;384(9948):1109-1117. doi: 10.1016/S0140-6736(14)60958-2.

Furnham A, Boo HC. A literature review of anchoring bias. 

Articles

You may rely too heavily on the information provided by another physician, which is (un)popularly known as “anchoring bias.”

Anchoring Bias: Is It Real?

I walked into an examination room at our multidisciplinary breast clinic to see Jill, a 25-year-old single elementary school teacher who was recently diagnosed with breast cancer. Jill was a known BRCA gene mutation carrier, and her mother and a cousin were currently receiving treatment for breast cancer. Because her cousin was diagnosed at age 35, Jill opted to start screening at age 25. During Jill’s first screening, cancer was detected, and it had already spread to her axillary lymph nodes. Jill arrived at the appointment with her parents. When I asked her why she was seeking care at our clinic, because she and her mother reported that they were extremely happy with the treatment her mother was receiving at an outside institution, Jill replied that she was interested in fertility preservation and knew she would have options at a tertiary care center.

As I discussed fertility-preservation options with Jill and her parents, I felt sadness and also guilt, as I was obviously pregnant. It seemed especially cruel for Jill to hear about fertility options from a young pregnant fellow. Jill smiled and politely asked questions about how I was feeling with my pregnancy as a breast surgery fellow even though she was the one with a life-altering diagnosis. I felt fortunate to be healthy and expecting my first child.

One of the most difficult things as a breast surgery fellow is treating young women with cancer, some even younger than myself, in the early stages of their lives. Seeing these women and their families attempt to cope with their diagnosis and treatment is heartbreaking. Young women should be concerned about job challenges, family issues, and life goals—they should not have to worry about cancer and mortality.

Oncofertility, a term coined by Teresa Woodruff, PhD, of the Oncofertility Consortium, is the specialty dealing with the clinical care of patients who will lose their fertility due to cancer treatment. Oncofertility is very important in the care of patients with breast cancer for multiple reasons. Nationally, there is a trend toward more women delaying motherhood and having children at older ages. Also, more patients are surviving breast cancer and may become mothers after treatment—and more women certainly will have the life expectancies to be able to parent their children.

In 2006, the American Society of Clinical Oncology (ASCO) released recommendations regarding oncofertility; these recommendations were updated in 2013.

 Providers are encouraged to discuss the possible loss of fertility with reproductive-age patients with cancer, as well as refer patients to appropriate fertility preservation specialists. ASCO suggests this discussion should be documented in the medical record. There are multiple options for fertility preservation including embryo and oocyte cryopreservation.

Oncologists have often led the way in terms of discussing oncofertility with patients, as both chemotherapy and endocrine therapy impact ovarian function. However, surgical oncologists should discuss this important topic with their patients, as well. Surgeons are generally the first providers that patients interact with following a cancer diagnosis. There is an opportunity and obligation to discuss fertility concerns with any woman of childbearing age. Fertility preservation efforts can begin during workup prior to surgery, as patients wait for surgery, and as patients recover after surgery. These processes can take place concurrently, as fertility preservation procedures will not affect the cancer surgery or vice versa. Referring patients to a reproductive specialist at the time of the first appointment can save valuable time, as hormone stimulation can require weeks of treatments prior to the retrieval procedure.

Jill underwent oocyte cryopreservation after meeting with a reproductive specialist. While undergoing neoadjuvant chemotherapy, she is considering her surgical options. I am hopeful that she will be able to have a child after she is treated for her cancer.

Now that my son has arrived, it has hit home how important it is to discuss fertility preservation options with our patients. Women need to hear that breast cancer is treatable, their fertility can be preserved, and they can become mothers despite their diagnoses. Our sole focus should not be just treating the cancer. We must treat the whole patient, taking into consideration survivorship issues and oncofertility at the very first appointment.

Loren AW, Mangu PB, Beck LN, et al. Fertility preservation for patients with cancer: American Society of Clinical Oncology clinical practice guideline update.

 2013;31(19):2500- 2510. doi: 10.1200/JCO.2013.49.2678.

Oncofertility is the specialty dealing with the clinical care of patients who will lose their fertility due to cancer treatment.

Helping Patients With Cancer Address Fertility Challenges

Life has definitely kept me busy, and it seems to get busier by the minute. However, I’ve never been more ecstatic about where I am and what I’ve accomplished thus far in establishing a career in medicine. My journey hasn’t been an easy one as many who choose to enter the medical field know.

It’s been said that getting into medical school is one of the toughest steps in one’s medical career. Although I had cleared the hurdle of getting accepted, I experienced some moments throughout medical school where I thought graduating would not be feasible.

While I did start to cultivate my interest in hematology/oncology as a second-year medical student, my grades also began to suffer once clinical rotations commenced. It was extremely challenging and intimidating for me to go from one rotation to the next and be expected to adjust every 1 to 2 months. We all wanted to appear as knowledgeable as possible in order to impress our attending and resident physicians for that grade we needed to earn the top spot in our desired specialty. Adding to that stress was finding enough study time to obtain a decent grade on the shelf exams, which were the written portions of the clerkship rotations. I quickly learned that, even with an excellent clinical score, if my shelf exam score was below average, my total course grade would suffer and, consequently, affect my transcript.

At one point, I was terrified that I wouldn’t be able to move forward into residency to pursue the career I dreamed of—becoming a hematologist/ oncologist. I had doubts and some of my attendings had doubts about me as well. There were times when I wasn’t sure if I was good enough for residency and questioned whether or not hematology/oncology was really the right specialty for me. Generally, when faced with a decision, I am the type who needs time to sit and ponder before finalizing everything. Now, looking back, I feel that my third year of medical school was extremely rushed and I did not have sufficient time for reflection.

However, things began to change for me between my third and fourth years of medical school. Based on my experiences, I decided that I would need some time to improve my résumé, and conduct research to show that, despite my grades, I desired and was worthy of a career in hematology/oncology.

This led to my research on sickle cell disease, which resulted in a poster presentation at the American Society of Hematology Annual Meeting in 2011. This accomplishment really brought me the confidence boost I needed to move forward in applying for residency. I felt extremely blessed to have the opportunity—as a student–to present my research in my desired specialty at such a prestigious national-level meeting. While I found it overwhelming to keep track of all of the lectures at the meeting, I was simultaneously extremely excited to be a part of the hematology/oncology community when so many new drugs and treatments were being developed. I recall one striking presentation that reviewed the groundbreaking discovery of imatinib, a tyrosine kinase inhibitor used to treat chronic myelogenous leukemia. It was that presentation, that confirmed my resolve to be a part of this field in medicine.

Then along came residency. My intern year was fairly strenuous and physically laborious. It involved working long, inconsistent hours, primarily at night, and there were several emotionally draining moments. However, once my second year started, I poured my heart and soul into preparing for fellowship. I participated in lymphoma research and attended multiple malignant hematology clinics. This is my field of interest and I’ve become convinced that this is the subspecialty for me. I love understanding the physiology behind various hematological diseases and the science and research that is directly incorporated into the treatment of these patients.

Now, I am starting my second year of fellowship. My first year was a bit grueling with many required inpatient duties, but I survived. My excitement for my work has not waivered, despite occasional tough home-call nights and long demanding hours on the bone marrow transplant service. In fact, my passion for hematology/oncology has only been further substantiated by all that I saw and learned throughout my first year. Throughout my second year of fellowship, I’ll be learning more about managing my patients (physically and mentally) in the outpatient setting, which, in my opinion, is where all the action occurs.

The challenges we face now are quite different from those of medical school or residency. Although our work is less laborious, there are more academic obligations. Also, as oncologists, we develop a close bond with the patients we see and treat. So, as expected, when any of them die, it is extremely heartbreaking as we’ve become so attached and strongly linked with them. We can only hope for the best, although we know that the worst is more likely. I believe that recognizing all of this is imperative to becoming a better physician for my patients. Yes, knowledge is important, but so is compassion, warmth, and honesty. Not everyone will want the treatment that I recommend, but they will still need my emotional support when they are in their darkest hours of battling their diseases.

Every new visit with a patient during which I discuss a diagnosis can be challenging. It is similar to giving a death sentence, which happens more often than not in my specialty. While providing information on the cancer and treatment gets a little easier with time, empathizing and accepting the emotions that patients and their families express does not. My attendings who train me are exceptional. There seems to be such a close camaraderie among everyone, which allows for a harmonious work environment.

There are, at times, some rough patches, but overall, I couldn’t have asked to be a part of a better fellowship program. With each day of fellowship, I am reminded of how happy and lucky I am to be on the path toward becoming a full-fledged hematologist/oncologist. It wasn’t an easy journey getting to fellowship, but I’m more than ecstatic to finally be here. Now, only time will tell what the future has in store for me.

While providing information on the cancer and treatment gets a little easier with time, empathizing and accepting the emotions that patients and their families express does not.

March 2017 | Oncology Fellows

Anchoring Bias: Is It Real?

Helping Patients With Cancer Address Fertility Challenges

Reflections of a Growing Oncologist