He had severe right chest and shoulder pain.
His doctor had said it was the tunneled dialysis catheter. “If the pain gets worse go to the ED to get it removed.”
The nurse’s note told me the problem: “dialysis catheter pain”. He could not lie flat or move his shoulder. It hurt to breathe.
He didn’t want pain medication, nor an IV, nor an exam. “Just remove the catheter and make the pain go away.”
But something wasn’t right. What else? What else could this be?
There was no redness. No fluctuance. No pain on palpation at the catheter site. But his right arm. Maybe it was swollen. The ECG and chest xray were normal.
I bet he has a blood clot in his IVC. I ordered a CT Scan of the Chest.
There was a blood clot. At the tip of the catheter extending about 2 cm. Non-occluding.
I called the Hospitalist. I called the Nephrologist. I filled out the transitional admission orders: “Remove the tunneled catheter and perform dialysis.”
But something wasn’t right. A 2 cm clot and that much pain. What else could it be? The pain was out of proportion to the findings. I must have missed a PE.
I pull up the CT again. I don’t see a PE. But I do see something else.
A large invasive right subscapular cystic mass. Both the radiologist and I had missed it. We had anchored on the dialysis catheter. The simple answer was not correct.
Anchoring bias is when we rely too heavily on one piece of information when making decisions. We see the first single answer and stick to it. We find results that prove it. We close our mind. We make our decision too early.
It is one of the most common cognitive biases. Anchoring bias in medicine is responsible for significant morbidity and mortality.
Ask “What else?” Before each procedure. Before each admission or discharge. With each patient touch. Structure time and space to ask yourself, “What else could this be?”. “What am I going to miss on this case?”