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Anchoring is a term you start to hear a lot more as you begin your clinical rotations.

Attendings will advise you to avoid anchoring on a diagnosis. I call this the “bad” kind of anchoring.

The “bad” kind of anchoring is a bias that occurs when we anchor on a particular reference point or conclusion. After we “anchor,” subsequent information is interpreted or understood differently based on this bias. When we anchor on a diagnosis prematurely, we are at risk of ignoring or misinterpreting contradictory information.

The propensity to anchor is described as a test-taking weakness:

“Learners who exhibit this deficiency make an early decision on the diagnosis, ignore or downplay information inconsistent with the diagnosis, and may list facts that are inconsistent with the chosen diagnosis or simply fail to note the inconsistencies.”1

You may recall earlier advice detailed throughout this book, especially in Chapter 2, to “anchor” on a diagnosis or conclusion. This is the “good” kind of anchoring. This advice is designed to prevent new information from confusing you or clouding your judgment after having made a conclusion.

What is the difference between the “good” and the “bad” kind of anchoring?

The “good” kind of anchoring should provide you with enough confidence in your conclusion, but not so much that you ignore new, pertinent information. We want to remain flexible enough to carefully consider whether new information should affect our conclusions.

We need to learn to strike a balance between the “good” and the “bad” kind of anchoring.

Let’s work through an example.

Imagine a female patient presents to the emergency department with right lower abdominal pain for one day. It is severe and sharp. The pain was more diffuse earlier in the day and now feels more localized to the right lower quadrant. She has had a loss of appetite and one episode of emesis just prior to her arrival in the emergency department.

Do you know what the diagnosis might be?

Most of us probably suspect appendicitis. This is a common diagnosis and everything we know so far fits.

The “good” kind of anchoring will help us to focus our attention and stay on track. But the “bad” kind of anchoring could bias us towards appendicitis before we have enough information to make a conclusion.

We don’t know yet if the correct diagnosis is indeed appendicitis.

What are some other possible diagnoses?

This patient might have ovarian torsion, a tubo-ovarian abscess, malignancy, or even just severe constipation.

Imagine we learn that the patient is afebrile and tachycardic.

How do her vital signs change your differential?

Appendicitis often ...

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