Cognitive Processes in Anesthesiology

January 29, 2020

When humans are responsible for performing a task or making a decision, there is always a certain level of “human error.”1 Industries that are run by and largely consist of humans, such as aeronautics, factory production and health care, are particularly subject to such mistakes.1 Clinicians can be affected by cognitive biases,1 failures in perception2 and heuristics (or “rules of thumb”),3 all of which affect proper medical care. Though contemporary medicine relies on evidence and rational decision-making, face-to-face patient care can make it difficult for clinicians to avoid cognitive errors.2 As humans, anesthesia providers make cognitive errors in emergency and non-emergency situations.4 In order to anticipate and prevent cognitive errors, anesthesiology professionals should familiarize themselves with common mistakes in anesthesiology and cognitive aids that may help alleviate their mental load.

Anesthesia providers may fall prey to cognitive error during critical and non-critical situations. A study by Stiegler et al. found that in over half of 38 simulated anesthesiology sessions, resident physicians showed cognitive biases such as premature closure, or acceptance of a diagnosis before it had been fully verified; confirmation bias, or use of evidence as confirmation of the desired or suspected diagnosis; sunk costs, or unwillingness to let go of a failed diagnosis or decision, especially if much time and resources had been allocated; commission bias, or tendency toward action rather than inaction; omission bias, or hesitation to start emergency procedures for fear of being wrong or causing harm; and anchoring, or heavy dependence on an initial piece of information that was not important.4 Surveyed academic anesthesiology faculty had difficulty selecting only five common cognitive errors because they felt they all occurred with similarly high frequency.4 A later review paper by Stiegler and Tung focuses on how logical models of decision-making, such as expected utility, Bayesian probability and formalized pattern-matching, are altered by biases, overconfidence, memory error, preferences for certainty, framing, loss aversion and emotion.5 These cognitive errors can lead anesthesia providers to deny that an airway is difficult, to refer to medical cases that are covered in grand rounds, to worry about appearing incompetent and to accept a good outcome even if the process was extremely risky.5 According to Chandran and DeSousa, research shows that human factors account for 83 percent of the work in anesthesiology; thus, cognitive errors can lead to anesthetic errors and crises.6 A combination of non-routine events and human factors allows for many cognitive errors with potentially catastrophic results.6 Meanwhile, Naguib et al.’s study found that even routine events can be accompanied by cognitive error.7 Of 1629 anesthesiologists in a survey on the use of neuromuscular blocking drugs, 1496 (92 percent) expressed overconfidence.7 Cognitive errors can play a large role in an anesthesia provider’s practice, which is particularly dangerous given the importance of human factors in quality of anesthesiology care.

Fortunately, anesthesia providers can use various strategies to lighten their cognitive loads and avoid errors. Chandran and DeSousa suggest myriad ways for anesthesiology practitioners to reduce human error, such as cognitive debiasing strategies and practical solutions.6 Cognitive debiasing strategies include insight development through learning about biases, consideration of alternatives, metacognition (thinking about thinking), lower reliance on memory, specific trainings to overcome flaws, simulation exercises, cognitive forcing strategies, minimized time pressures, accountability and reliable feedback.6 Practical solutions to reduce cognitive error include checklists, resuscitation training or simulations, stress and fatigue management, standard operating procedures or protocols, communication and teamwork.6 Stiegler and Ruskin suggest that anesthesiology practitioners adopt tools originally from the aviation sector to determine risks associated with a particular clinical strategy.8 Another article by Stiegler et al. states that anesthesia providers can benefit from educational strategies to improve decision-making, such as targeting rationale instead of behavior and employing cognitive self-monitoring strategies, decision support tools and algorithmic cognitive aids.5 However, the authors note that the data are limited on efficacy of such decision-making aids in improving patient care.5 Marshall’s literature review found mixed evidence on cognitive aids for anesthetic emergencies, with some simulation-based studies showing either no improvement, slower diagnosis or more errors with the aids.9 While Schild et al. assessed the usability of digital cognitive aids for intraoperative crisis management, they did not use a simulation-based evaluation.10 While cognitive debiasing and practical strategies may be useful in reducing cognitive error, there are few studies on care-related outcomes.

Like all humans, anesthesia providers are prone to making cognitive errors due to biases, perception issues and the use of shortcuts and heuristics. Cognitive biases such as premature closure, confirmation bias, sunk costs, commission bias, omission bias and anchoring, as well as memory errors and emotion, can affect quality of patient care. While anesthesia providers can use strategies such as metacognition and simulation exercises to limit error, there are few studies testing the efficacy of these strategies. High-quality studies and studies about cognitive aid creation and standardization are sorely lacking.11 Future research should take a discipline-based approach by focusing on strategies for anesthesiology and how they affect patient care.1

1.         Saposnik G, Redelmeier D, Ruff CC, Tobler PN. Cognitive biases associated with medical decisions: A systematic review. BMC Medical Informatics and Decision Making. 2016;16(1):138.

2.         Croskerry P. The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them. Academic Medicine. 2003;78(8):775–780.

3.         McGee DL. Cognitive Errors in Clinical Decision Making. Merck Manual: Professional Version. Kenilworth, New Jersey: Merck & Co., Inc.; November 2018.

4.         Stiegler MP, Neelankavil JP, Canales C, Dhillon A. Cognitive errors detected in anaesthesiology: A literature review and pilot study. BJA: British Journal of Anaesthesia. 2011;108(2):229–235.

5.         Stiegler MP, Tung A. Cognitive Processes in Anesthesiology Decision Making. Anesthesiology: The Journal of the American Society of Anesthesiologists. 2014;120(1):204–217.

6.         Chandran R, DeSousa KA. Human factors in anaesthetic crisis. World Journal of Anesthesiology. 2014;3(3):203–212.

7.         Naguib M, Brull SJ, Hunter JM, et al. Anesthesiologists’ Overconfidence in Their Perceived Knowledge of Neuromuscular Monitoring and Its Relevance to All Aspects of Medical Practice: An International Survey. Anesthesia & Analgesia. 2019;128(6):1118–1126.

8.         Stiegler MP, Ruskin KJ. Decision-making and safety in anesthesiology. Current Opinion in Anaesthesiology. 2012;25(6):724–729.

9.         Marshall S. The use of cognitive aids during emergencies in anesthesia: A review of the literature. Anesthesia & Analgesia. 2013;117(5):1162–1171.

10.       Schild S, Sedlmayr B, Schumacher AK, et al. A Digital Cognitive Aid for Anesthesia to Support Intraoperative Crisis Management: Results of the User-Centered Design Process. JMIR mHealth and uHealth. 2019;7(4):e13226.

11.       Gaba DM. Perioperative Cognitive Aids in Anesthesia: What, Who, How, and Why Bother? Anesthesia & Analgesia. 2013;117(5):1033–1036.