I first met Mr. T during my surgical clerkship when he was hospitalized for sepsis related to fistulizing wounds. Every morning around 5:40, we would greet him and then roll him onto his side and pull down the tape from the tunnels and sinuses, clean off the pus, and replace the gauze in his wounds. It was clearly painful for him, yet he was gracious all the time. He and I even bonded a bit for having lived in the same rural small town. Mr. T was one of the first patients I connected with deeply.
Five months later, I ran into Mr. T on my first day on a general medicine team. He had been admitted once again, this time for septic shock complicated by a myocardial infarction, and had just been downgraded to our team. He was as friendly as ever, had a bit more energy than when I met him the first time, and was unbelievably positive. He also had persistent borderline hypotension, and his wounds continued to heal poorly. Still, we continued to treat him. He wasn’t unstable to the point of crashing, and he remained asymptomatic.
But then something happened: On a night that I wasn’t there, after having taken care of him for a couple of weeks, Mr. T was upgraded to the ICU.
When I heard the news, my stomach sank. I’m not sure if the team could have prevented this transition in care, but I was filled with surprise and disappointment. I couldn’t believe that I hadn’t seen this coming. I wondered: Did my friendly rapport with Mr. T reduce the thoroughness of my investigation into his ailments? Did I not ask him a question I should have, because I trusted him and his positive attitude? Perhaps the rest of the team had an inkling that something was brewing, but my nascent clinical intuition had missed the signs if they were there.
This case showed my vulnerability to several cognitive biases. The affect heuristic was at play here: I had positive feelings about Mr. T because he was familiar and friendly, which may have swayed my interpretation of clinical data.
Additionally, there’s also the representativeness heuristic. Mr. T didn’t necessarily “look” like the stereotypical sick patient — he was optimistic and never complained. He didn’t “seem” ICU-bound — and certainly not as “sick” as other patients that I’d treated.
The representative heuristic in particular can be highly problematic — it can lead us to prognosticate more favorably in our own minds or suggest a plan that is slightly more comfortable for patients who seem healthy and happy, even if that is not reflected in their objective diagnostic workup. Here, I had to ask myself: Did I not do the more invasive physical exam on Mr. T, this patient I knew well and had positive feelings toward, because I wanted to let him sleep or rest comfortably?
Fortunately, Mr. T ended up recovering well and received the care he needed. However, the situation was a wake-up call. Although I’ll never know if he went to the ICU because of something I missed, I have a new resolve to become more accurate in estimating prognosis and diagnostic likelihoods, and suggesting plans. I know that as I grow in my knowledge and experience, this will come — but in the meantime, awareness of biases, especially around friendly, positive patients, is an important step. As a doctor, I will have a responsibility to not let wishful thinking about patients that I get along with sway my recommendations for them to do things that might be warranted, even if they are invasive or uncomfortable.
At this stage of my training (and likely throughout its course, although I’ll reserve judgment on that for once I get there), subconscious reliance on heuristics is especially hazardous due to a fledgling cognitive framework of disease. As I develop my understanding of pathology and disease course through study and experience, I anticipate that I’ll develop a more robust and accurate clinical intuition. I suspect that combating cognitive biases will continue to be relevant to my practice, although it’ll take different forms as my reasoning develops. For now though, I should have healthy fear and self-skepticism as I grow in experience, and strive to always be thorough and intentional in my evaluation of patients.
Have you ever fallen prey to a cognitive bias in patient care? Share your experience in the comments.
A. Hayes Chatham is a medical student in Gainesville, Florida. He is a 2025–2026 Doximity Op-Med Fellow.
Patient name and identifying details have been changed.
Image by Alphavector / Shutterstock
