Ep61 | The First Story Wins: Anchoring Bias in Diagnosis, Conflict and Clinical Leadership

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If you work in healthcare, [music] you already know this. Conflict is everywhere. In the O, in labor and delivery, in committee meetings, between

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physicians, nurses, administrators, and teams that are all trying to do the right thing. But here's the problem. Most of us were never trained to handle conflict well. We learned procedures. We learned diagnostics. But we didn't learn how to navigate the moments when Q professionals strongly disagree. That's [music] why I developed the Spark Framework. Spark stands for stop, pause, ask, don't assume, reflect, and respond, and create a path forward. It's a practical system designed specifically [music] for highstakes healthc care environments through keynote talks, residency workshops, and spark master classes. I [music] teach physicians, nurses, and healthcare teams how to turn destructive conflict into productive [music] conversations that strengthen teams and improve care. If your hospital, residency program, or medical conference is looking for a speaker on conflict, communication, and leadership, and healthcare, [music] I'd love to work with you. You can learn more in the show notes because in medicine, conflict is inevitable,

Podcast Intro and Anchoring Bias Overview 2:25

but handled well, it can make teams stronger. In every operating [music] room, in every ward, in every clinic and every team meeting, a silent battle bruise, conflict, negotiation, identity. Welcome to the Scalpel and Sword podcast where I, Dr. Lee Chararma, [music] physician and conflict analyst, explore the hidden negotiations beyond modern medicine. Let's trade burnout for boundaries [music] and learn the art of healing with precision and power. Hello my peaceful warriors and welcome to the scalpel and sword podcast. I am your host Dr. Lee Chararma, physician and conflict analyst. And today we're going to discuss a cognitive trap. Something that affects nearly every physician, nurse, administrator, patient, and healthc care leader at some point in their career. It's a concept called anchoring. Anchoring is one of the most powerful and dangerous biases in medicine. It can lead to a misdiagnosis. It definitely fuels conflict. It can damage relationships. And perhaps most importantly, it can prevent us from seeing reality as it actually is. The irony is most of us believe anchoring is something that happens to other people. Today we're

Anchoring in Clinical Reasoning 4:07

going to explore how anchoring affects clinical reasoning, conflict resolution, leadership decisionm and how we can protect ourselves from its influence. So what is anchoring? Anchoring occurs when we become overly dependent on the first piece of information we receive. psychologist Amos Diverski and Daniel Conamoran, which if you've never read Thinking Fast and Slow, by all means go buy that book now. System one and system two thinking should be required education for every physician and medical student. But they are the ones who first described anchoring as one of the most pervasive cognitive biases in human decision-m. Once an anchor is established, once we have latched on to this thought, subsequent information tends to be interpreted through that anchor. So what does this sound like in medicine? It often sounds like when the patient comes in with chest pain, this is probably reflux or this is just anxiety. Patient has a fever, it might sound like this is just another viral illness. If unfortunately we're making value judgments about the presenting patient, sometimes it can sound like this patient always exaggerates symptoms. Once the anchor is set, our brains unconsciously begin searching for evidence that confirms the initial impression rather than the evidence that challenges it. We stop asking what else could this be and instead we start thinking how does this fit my original impression. The distinction is subtle but the consequences can be enormous.

So imagine a 42year-old woman presenting to the emergency room with chest pain. She has a history of anxiety. The triage note mentions significant stress at work. Before the physician even enters the room, an anchor has already been placed. Anxiety, stress, she's having a panic attack. As the history unfolds, every detail begins to get filtered through that lens. Her teacardia is anxiety. Her shortness of breath is anxiety. her chest pressure anxiety until eventually someone remembers to obtain a d-dimer and she has a pulmonary embolism. The issue isn't that anxiety wasn't on the differential. The issue is that the anxiety became the anchor. Studies

Anchoring in Workplace Conflict 6:49

repeatedly show that diagnostic error often results not from a lack of knowledge but from cognitive shortcuts. Physicians frequently know the correct diagnosis. They simply stop looking before they find it. Anchoring combines with another bias called premature closure. We decide and then we stop thinking. In many malpractice cases, the problem is not ignorance, it's certainty. The first explanation becomes the only explanation. Anchoring doesn't just happen with diagnosis, however. It happens with people. Consider rounds. An attending physician offers an early impression. Suddenly, every resident and student begins interpreting information through that framework.

Even when contradictory evidence emerges, team members hesitate to challenge the anchor. The first story gains power. The higher status individual who delivers it gains even more. Health care culture sometimes unintentionally rewards agreement over inquiry. But patient safety depends on someone asking what if we're wrong. One of the most valuable phrases in medicine may be help me consider and understand an alternative diagnosis. Curiosity should always be driving the bus. Now, let's move from the exam room to conflict because anchoring profoundly affects disagreements just as profoundly as clinical diagnosis. Imagine a nurse and a physician who have had a difficult interaction. The physician raises his or her voice during a stressful emergency.

The nurse leaves feeling disrespected. An anchor is formed. This physician doesn't respect nurses. Every future interaction is now filtered through that story. A delayed response to a message. Proof. A brief curt answer. More proof. Failure to make eye contact. The anchor begins collecting evidence and then what gets ignored? All the interactions that don't support the narrative. The physician may have been overwhelmed, may have been distracted. They may be concerned about a critically ill patient. They may be having a terrible day. But once the anger is established, alternative explanations

Using the SPARK Framework to Respond 9:35

become harder to see. Conflict frequently begins not with facts but with interpretations, assumptions. And interpretations often become anchored early. Listeners of this podcast know that I will often talk about something called a conflict iceberg. Above the surface, policies, schedules, budgets, behavior, but below the surface of the water, identity, values, assumptions, worldview, the construction of our previous stories and experiences that we have shared with ourselves. Anchoring occurs below the surface. Someone misses a deadline. The visible event is simple, but the anchor becomes they're irresponsible.

Someone challenges your proposal. The anchor becomes they're undermining me. Someone disagrees with your recommendation. The anchor becomes they don't trust me. Once these assumptions take hold, they become surprisingly difficult to dislodge. What's fascinating is that diagnostic error and conflict share the same cognitive mechanism. In both cases, we see something, we tell ourselves a story, and then we defend that story. Physicians often think diagnosis is objective and conflict is subjective.

But both rely heavily on interpretation. In diagnosis, symptoms become a narrative. In conflict, behavior becomes a narrative. The danger occurs when we mistake our narrative for reality. The patient isn't the diagnosis. The colleague isn't the story that we've assigned to them. Reality is more complicated and more interesting. The best diagnosticians and the best conflict navigators share a common trait, curiosity. They remain willing to be surprised. They are willing to question. They're willing to dig deeper and they're willing to be open to the possibility that there may be another explanation.

So this is where spark our framework for conflict becomes incredibly valuable. So in our spark framework S stands for stop which is an external pause. Pausing is an internal process where we're stopping to take stock of where we are emotionally and take a second to ask what our own assumptions are. parents. Don't assume is the antidote to making those assumptions because we're digging deeper. Reflect and respond means that we're actually taking time to consider the possibility that there may be a different explanation. And C, create means that we've actually going to create another pathway, a different level of understanding. When we stop, we notice our certainty because certainty is often the first warning sign. The moment you think, "I know exactly what's happening is the time you need to pause because you may be anchored." The act of pausing creates a cognitive distance. A few seconds of reflection can interrupt automatic thinking. Ask yourself, what information am I missing? And when we ask without assuming, we can ask ourselves this very important question.

What diagnosis would most concern me if I missed it? The Society for Improvement

Curiosity, Conclusion, and Outro 13:44

in Diagnosis and Medicine, the SIDM, has a program called Teach DX where they actually teach clinicians to teach clinical reasoning to other physicians, residents, medical students, and advanced hip practice practitioners. So, in THDX, they have something called the can't misdiagnosis. So what we're doing when we ask and we don't assume is we're actually investigating what that can't misdiagnosis is and we are considering it. So what does that look like in conflict? It looks like what else could explain this behavior. These questions broaden the differential. We are no longer locked into one thing. We are open to potential. When we reflect and respond, instead of defending our anchor, we examine it. What evidence supports my interpretation and what evidence contradicts it? And if I was asking somebody who was completely new to the conflict situation or the patient presentation, what would that person see? And then we can create we can create a new possibility, a broader differential, a different narrative. We create space for another explanation. Spark doesn't eliminate anchoring, but it helps us recognize it before it causes harm. I'm going to leave you with a very simple thought experiment. A man walks into a clinic carrying a bouquet of flowers. Why is he carrying flowers? Maybe he's visiting a hospitalized spouse. Maybe he's apologizing. Maybe he's celebrating an anniversary. Maybe he's delivering them to a friend. Maybe they're for a funeral. The truth is that we don't know. But within seconds, our brains create a story and then we begin believing it. That tendency to create a story before we have enough information is deeply human. It's also potentially deeply dangerous. Whether we're diagnosing abdominal pain, managing workplace conflict, leading organizations, or raising families, the challenge remains the same. Don't fall in love with your first explanation.

Hold your conclusions lightly. Remain curious longer because the first story is often incomplete. And sometimes the difference between harm and healing is simply being willing to ask what else could be true. Thank you so much for joining me today on the scalpel and sword, my peaceful warriors. The next time you find yourself in a clinical situation or you feel a conflict coming on, be willing to embrace the possibility that there are multiple explanations. Embrace the process and path of curiosity. And until next time, be at peace.

Every episode [music] is an invitation to speak, to negotiate, to choose. I'm Dr. Lee [music] Chararma. Join the dialogue by subscribing to Scalpel and Sword. Until next time, peaceful [music] warriors. May your choices be sharp and your voice be even sharper. This podcast is a reflection of lived experience and research in conflict [music] resolution. The scalpel and sword is not intended as medical or legal guidance. For personal matters, please consult a qualified professional.