Avoiding Errors with How Doctors Think

Jarrod Shapiro, DPM Practice Perfect Editor Assistant Professor, Dept. of Podiatric Medicine, Surgery & Biomechanics College of Podiatric Medicine Western University of Health Sciences, St, Pomona, CA

We’re all aware that medical errors are a significant concern throughout the medical and lay communities. We commonly hear about patients receiving the wrong medication or the incorrect dose of the correct medication. We’ve heard about wrong site surgery and the national movement to prevent this unfortunate occurrence.  I’ve written previously about the World Health Organization’s Safe Surgery Saves Lives Checklist which has shown clinically significant decreases in intraoperative complications and all-cause morbidity. What I haven’t written about is, perhaps, an even greater source of errors:the way doctors think. When it comes to errors, there’s no greater number and significance than those by physicians, specifically errors of cognition.

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This topic was brought to my attention by one of our eTalk contributors who suggested we read a book called How Doctors Think, by Jerome Groopman, MD. I took the advice and read this very thought-provoking book. I was not surprised to find just how significant physician cognitive errors really are. For example, when studied objectively, 10-15% of all diagnoses are actually incorrect. If you think about this for a moment, I don’t think you’ll be surprised either.  Consider your daily practice. How many patients do you see daily who come to you for a second opinion or perhaps have undergone a surgical procedure, only to find the initial diagnosis was incorrect or the procedure failed to consider the most important pathological factors?  How many cases of heel pain have you seen diagnosed with “plantar fasciitis”, only to find it’s actually a Baxter’s neuritis, tarsal tunnel syndrome, or lumbosacral radiculopathy? Ever see a patient who’d previously undergone a Morton’s neurectomy without remission of her pain, only to find out she actually had a joint problem? I have. Pretty often, actually. Considering the fact that many people heal themselves despite their doctor’s treatment, I wouldn’t be surprised to find out that the 10-15% number is much greater.

One major commonality between the physicians Dr. Groopman interviewed is the way they pause for a moment before committing to treatment. They stop and ask themselves the one question all of us are trained to ask but too often fail to: can this be something else? Very simply, these doctors are running through a differential diagnosis. Most of us know the differentials for the vast majority of illnesses we treat, but do we take that moment of pause? Or do we simply so glad to have arrived at a plan of action, a treatment plan that will satisfy the patient, that we stop at that point. Are we blinded by the pleasure ones gets from knowing "what to do ?" Do you ask yourself, “Is this truly plantar fasciitis? Why does the patient’s pain worsen with activity? Is this consistent with plantar fasciitis or something else?” It may take a bit longer and require a more comprehensive workup, but it is better patient care.

The next step is to create the actual routine. How do you actually want the particular procedure to occur? Let’s take rooming a patient as an example. In my hypothetical office, my assistant simply sits the patient down in the room, tells the patient the doctor will be right with them and then closes the door. I’ve become frustrated, because I have to gather the patient’s past medical history and wait for them to take off their shoes. I want these things completed before I walk into the room.The other point I found fascinating were the various types of errors physicians commonly make. Here are a few examples:

1. Representativeness error – Thinking guided by a prototype, so the doctor fails to consider possibilities that contradict the prototype, attributing symptoms to the wrong cause. For example, thinking every patient with poststatic dyskinesia has plantar fasciitis and failing to consider a neurological contribution.
2. Attribution error – Preconceived notions about a patient lead the doctor to the wrong diagnosis. Your hypochondriac patient with foot pain may actually have something wrong.
3. Affective error – When the doctor prefers what he hopes will happen, valuing too highly information that fulfills his desires. Think of this potential error when your postop bunionectomy patient comes in with mild erythema around his surgical wound. You really want your patient NOT to have an infection, and not prescribing an antibiotic for this reason would be an affective error.

This is perhaps the most difficult part. The key to successful implementation of any new policy or procedure is communication with the staff. The first step is to add your new procedure in the appropriate section of your office staff manual. If you don’t have one of these, you should. Next, review the new procedure with all of your staff at the appropriate time. Take adequate time, either before or after patient hours (not in the middle of a busy day) to review the procedure. Demonstrate exactly how you want it done. Ask the staff to demonstrate the procedure so you can evaluate their proficiency. Ask for their input and suggestions and listen to those suggestions. Make this a positive experience, reinforcing the team, rather than making it seem mandated from above. Once your staff is proficient, have them start using the new protocol during patient encounters.

As a result of new research, several strategies have been reported to decrease physician cognitive errors. These strategies include considering alternatives (discussed above), metacognition (training for a reflective approach in decision making), and using diagnostic checklists, among others. For more information on this fascinating topic, read How Doctors Think and access the comprehensive research on the subject. No matter how long you’ve been in practice, I guarantee you’ve made (and may still be making) cognitive errors. Embrace this subject and be a better physician.

Get "How Doctors Think" by Jerome Groopman, MD at Amazon.  You can read other reviews of the book on this page at Amazon.

Keep writing in with your thoughts and comments. Better yet, post them in our eTalk forum. Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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