Cases & Commentaries
Spotlight Case: Anchoring Bias With Critical Implications
After multiple visits to both his primary care provider and urgent care for chronic burning left foot pain attributed to peripheral neuropathy, a man presented to the emergency department with worsening symptoms. His left lower leg was dusky and extremely tender, with non-palpable pulses. CT angiography revealed complete blockage of the left superficial femoral artery due to atherosclerotic peripheral arterial disease. The patient required emergent vascular bypass surgery on his left leg, and ultimately, an above-the-knee amputation. The commentary by Edward Etchells, MD, MSc, of the University of Toronto, explores cognitive biases that can contribute to diagnostic errors and recommends structured diagnostic assessments and computer–assisted diagnosis programs to augment diagnostic decision-making. (CME/CEU credit available.)
After multiple visits to both his primary care provider and urgent care for chronic burning left foot pain attributed to peripheral neuropathy, a man presented to the emergency department with worsening symptoms. His left lower leg was dusky and extremely tender, with non-palpable pulses. CT angiography revealed complete blockage of the left superficial femoral artery due to atherosclerotic peripheral arterial disease. The patient required emergent vascular bypass surgery on his left leg, and ultimately, an above-the-knee amputation. The commentary by Edward Etchells, MD, MSc, of the University of Toronto, explores cognitive biases that can contribute to diagnostic errors and recommends structured diagnostic assessments and computer–assisted diagnosis programs to augment diagnostic decision-making. (CME/CEU credit available.)
Anchoring Bias With Critical Implications 
Commentary by Edward Etchells, MD, MSc
The Case
A 61-year-old man with a history of stroke initially presented to his primary care physician (PCP) complaining of burning pain and numbness in his left foot for one month. The exam was notable for loss of sensation to his knee and a foot drop secondary to his prior stroke, but his pulses were intact with no other abnormalities noted. The PCP attributed the patient's pain and numbness to a peripheral neuropathy and referred him to podiatry.
The patient presented four more times to his PCP and twice to urgent care with a similar complaint of left foot pain. Each time he was referred to podiatry, but he never went to any podiatry appointments. During these visits, a complete extremity exam was not performed or documented, and the complaint was repeatedly attributed to his prior diagnosis of peripheral neuropathy.
After multiple visits to his PCP and urgent care over a 2-month period, the patient presented to the emergency department with worsening symptoms. On exam his left lower leg was dusky in color with extreme tenderness to palpation and his pulses could not be palpated. A computed tomography angiogram revealed complete occlusion of the left superficial femoral artery secondary to atherosclerotic peripheral arterial disease. The patient required emergent bypass surgery of the left leg by vascular surgery. Unfortunately, due to ischemia (lack of blood flow from the arterial disease) of his leg, he developed multiple infections postoperatively and ultimately required an above-the-knee amputation.
The vascular surgeons who cared for the patient believed the patient's chronic burning pain was likely due to progressive peripheral arterial disease and not to a peripheral neuropathy.
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