This is a piece in a series of blog posts where cognitive dispositions to respond, or biases, are discussed.

The introduction to the topic is here: On Critical Thinking and Decision Making

By Ginger Locke

tics and fleas

She warned us that patients could have “tics and fleas.” I was a paramedic student and one of the more keen professors often said, “Remember, patients can have tics and fleas.”

I wrongly assumed she was reminding us that patients can have lower acuity illnesses and that their complaint in not always attributable to an emergent condition. While this is true, I’ve since learned this isn’t what she meant by the phrase “tics and fleas.”

With this phrase, she intended to warn paramedic students to avoid a common cognitive pitfall called “Search Satisficing.”

The word “satisficing” was coined by American Noble-laureate Herbert Simon in 1956 and the word means what it sounds like it means. It’s a blend of the two words “satisfying” and “sufficing.” Satisficing is a decision-making short-cut, or heurtistic, that accepts a satisfactory solution, rather than the optimal solution. It describes a natural tendency for the human brain to accept a degree of inaccuracy in the interest of speed.  This cognitive disposition to respond is often observed when the decision-maker is operating in environments that are low in time and resources. Thus, it shows up frequently in Emergency Medicine.

Search Satisficing is the tendency for the clinician to call off the search once they have identified a cause of the patient’s complaint or condition. This tendency can be responsible for an error in the diagnostic process known as premature closure. In premature closure, the clinician ends the decision-making before collecting enough data to support or refute the working diagnosis.

The most referenced cases of search satisficing occur when looking for fractures on x-rays. The patient’s arm hurts. When a fracture is found, further investigation is stopped. The result of calling off the search is that a second fracture is missed. And this is what she meant by “tics and fleas.” The dog is itching. You find a flea. You stop searching and treat the dog for fleas. Unfortunately, the itching continues because they also have tics.

The phenomenon of search satisficing is commonly observed in cases of:

fractures (described above),

overdoses (the patient ingests more than one substance),

co-morbities (the COPD patient gets pneumonia),

and foreign bodies (such a relief to remove a foreign body! Keep searching.)

How to avoid this cognitive pitfall:

  1. Accept that you are as susceptible to the cognitive tendency as anyone else. Cognitive dispositions to respond are not tied to intellect.
  2. Create a favorable decision making environment. Fatigue, cognitive overload, sleep deprivation and “wicked” environments create higher risk for this error. In a future post, I’ll explain what Dr. Pat Croskerry meant when he referenced “wicked” environments.
  3. Use checklists and forcing functions.
  4. Practice meta-cognition. Think about your own thinking. Say to yourself, “Am I missing anything? Have I considered everything?”
  5. Off-load tasks. Delegate as much as possible in exchange for time to think.
  6. Get a second opinion. Say out loud to all members of the team, “Are we missing anything? Have we considered everything?”

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