Cognitive Bias: Premature Closure
The physician made the error of premature closure—accepting the first plausible diagnosis (acid reflux) without adequately considering or ruling out life-threatening alternatives like congestive heart failure when the patient presented with chest pain and shortness of breath.
Understanding the Error
This case exemplifies a classic diagnostic error pattern where the physician:
- Rapidly processed the patient's presentation and locked onto a single diagnosis (acid reflux) without broadening the differential diagnosis 1, 2
- Failed to recognize that chest pain and shortness of breath are cardinal symptoms requiring cardiac evaluation first, regardless of whether GERD seems plausible 3
- Committed premature closure of the diagnostic process, which is one of the most common causes of diagnostic errors reported by family physicians 2
The correct answer is B - First impression of the patient (premature closure based on initial impression).
Why This Error Occurred
Cognitive Factors
- Premature closure is the tendency to accept the first diagnosis that fits and stop considering alternatives 1, 2
- Physicians commonly fail to "look beyond the initial, most obvious diagnosis," which was identified as a key lesson learned from diagnostic errors 1
- Atypical presentations of serious disease (like CHF presenting as "acid reflux") are frequently missed 1
The Critical Missed Step
- Any patient with new chest pain requires cardiac evaluation first, regardless of how convincing the GERD presentation appears 3
- Approximately 30% of non-cardiac chest pain is caused by GERD, meaning 70% have other causes including cardiac disease 3
- The physician should have considered that "any discomfort above the umbilicus may be coronary artery disease" or cardiac pathology 1
What Should Have Been Done
Immediate Assessment Required
- Rule out cardiac causes through appropriate evaluation (ECG, cardiac biomarkers, clinical assessment for heart failure) before attributing symptoms to GERD 3
- Recognize that chest pain + shortness of breath is a high-risk presentation requiring urgent evaluation 4, 3
- If chest pain is unimproved or worsening after 5 minutes, emergency evaluation is mandatory 3
Proper Diagnostic Approach
- Broaden the differential diagnosis to include CHF, acute coronary syndrome, pulmonary embolism, and other life-threatening conditions 1, 2
- Only after excluding dangerous causes should a PPI trial be considered 4
- For patients with atypical symptoms (chest pain without classic heartburn), consider objective testing before empiric PPI therapy rather than assuming GERD 4
Common Pitfalls to Avoid
- Never assume chest pain is benign or GERD-related without cardiac evaluation, even when the presentation seems to fit acid reflux 3
- Avoid anchoring on the first diagnosis that comes to mind—this is the essence of premature closure 1, 2
- Be alert to atypical presentations of serious disease—CHF can present with symptoms mimicking GERD 1
- Hurry and distraction are the most common physician stressors leading to diagnostic errors 2
The Lesson
The physician's error was cognitive bias (premature closure), not simply being rushed (option A) or poor communication (option C). While those factors may have contributed, the fundamental problem was accepting the first impression without considering life-threatening alternatives 1, 2. This represents a failure in the diagnostic reasoning process where the physician stopped thinking too soon 5, 2.