Most physician errors are not intentional, but intent is not required in a medical malpractice case. The standard is whether a physician acts reasonably careful under the circumstances. This means that a physician can still be negligent even with the best of intentions.
It is important to remember that physicians are human beings. As such, they are susceptible to cognitive biases just like every else. But, when these cognitive biases affect medical care, the results can be catastrophic.
Consider the following example. A patient presents to a physician with concerns of anemia and lab tests are ordered. The results reveal a hemoglobin level of 10 grams per deciliter. This patient is not determined to be severely anemic and did not receive treatment; however, if the patient had a hemoglobin level of 9.9 grams per deciliter, the patient would been perceived as severely anemic and received the necessary treatment. There is no clinical significance between the two values, but just because the later value begins with a “9” the interpretation is that the value is much more severe.
This is called “left digit bias.” We see this bias every day when we purchase products. $1.99 for a package of gum is really the same as $2.00 for the same pack of gum, but just because the price begins with a “1” we think it is cheaper. It is natural for our minds to round to the left most digit.
Another common cognitive bias is called “confirmation bias.” People tend to receive information in a way to confirm his or her preconception. For example, if a patient presents to the emergency room in February with a cough, body aches, and a fever, his symptoms are consistent with the flu, no lab tests are ordered and the patient is sent home and told to get rest. The patient returns home and gets worse. He comes back to the emergency room and this time laboratory results show a severely elevated White Blood Cell count, indicative of a severe infection.
In this simple example, the physician likely thought that the patient had the common flu because it was that time of year and some symptoms were consistent with the flu. Essentially the physician came to a diagnosis and then interpreted symptoms consistent with that diagnosis. Unfortunately, this bias caused the physician to neglect other potential, even more life threatening, diagnoses.
Another similar bias is called “anchoring.” This is unfortunately a very common bias that is seen in medical malpractice cases. Essentially this bias occurs when a physician jumps to an initial diagnosis and each subsequent physician that sees that patient will follow that diagnosis.
Consider a patient presents to the hospital with pain during urination and abdominal pain radiating to the lower back. These symptoms are very common with a urinary tract infection, and the emergency room physician diagnoses as such. However, because of this anchoring bias, the emergency room physician failed to consider that the patient may have a much more serious condition, an abdominal aortic aneurysm. The patient then is seen by other physicians prior to discharge home. Using the initial diagnosis of a urinary tract infection as an “anchor,” each subsequent physician confirms the initial diagnosis and neglects to consider the possibility of an abdominal aortic aneurysm. The patient is discharged home and the aneurysm ruptures the next day.
Finally, another very common bias is called the “availability bias.” This bias plays out when physicians allow available information and experiences to affect the way they treat patients. For example, consider a physician deciding whether to order a specific medication for a patient. Over the past several months the physician has had reports of patients that have experienced unlikely side effects from this medication – so the physician decides not to order the medication, even though this particular patient had a condition that called for the use of the medication and the efficacy of the drug had not changed.
Unfortunately, biases like these are normal and all too common. The Patient Safety Network of the US Department of Health and Human Services estimates that about 75% of diagnostic errors have a cognitive component. These biases effect our daily decisions, but when the biases interfere with medical decision making the results can be life or death.
It is important to be aware of these potential biases and advocate for appropriate medical care. Ask questions of your providers and make sure they are considering all possible diagnoses or treatment options.
