When we get it wrong at work…how does it feel?
If we make a mistake in provisional diagnosis and treatment…how does it affect our patient?
For those of us who feel comfortable that we’ve been "in the game" long enough that we don’t need to be concerned, it’s vital to remember that it’s not just new paramedics and healthcare professionals making errors. One of the most common causes of medical mistakes and misdiagnosis is that of overconfidence.
In the case of paramedics, we often remain oblivious to any incorrect clinical interpretations, as we are not providing our patients with an official diagnosis and we don’t often see them again. Any alteration in treatment pathways will usually occur in hospital, once more specific diagnostic tests and assessments have been completed. It is possible, therefore, that without recognition of such errors and their associated humbling emotions, we are at risk of becoming overconfident.
This does not simply mean complacency (although that features in the mix) it is often related, instead, to experiential bias. We throw around the term “differential diagnosis” with great frequency in teaching, but how much time do we spend teaching its finer points, including, most importantly, the avoidance of bias in our decision-making skills?
All paramedics, amongst a group possessing equal levels of education, clinical training, and experience, will all assess and analyse each situation slightly differently, often reaching different conclusions. The subconscious process of integrating a patient’s medical history, signs, symptoms and assessments, with our medical knowledge and experience, can often be influenced by four varying types of bias, without us even realising it.
Availability bias regarding which conditions are at the forefront of our minds and are therefore easier to retrieve. In a healthcare setting, a practitioner is more likely to re-diagnose conditions that they have recently encountered, than consider other options less common, frequent or recent to their experience.
Representative bias around the similarity of signs and symptoms we may have seen before, whereby it appears obvious, therefore we may forget to investigate similar conditions. A study of both qualified and student healthcare providers found that adding a suggestion of unrelated social factors to patient history swayed their decision making, so that an otherwise clear diagnosis may instead veer towards a social or situational cause. For example, simply stating that alcohol could be smelt on a patient's breath, or the patient was recently made redundant, influenced the clinician to such a degree that, despite clear evidence of textbook CVA and STEMI symptoms, they were less likely to be diagnosed accurately.
Anchoring bias through which we set our thoughts so firmly on the things we know, or have seen before, rendering us unwilling and possibly incapable of changing our minds to incorporate new knowledge or data. This can be highlighted in situations whereby diagnosing clinicians remain firm in their decision, despite diagnostic evidence and/or autopsy later contradicting their initial opinions.
Anchoring bias through which we set our thoughts so firmly on the things we know, or have seen before, rendering us unwilling and possibly incapable of changing our minds to incorporate new knowledge or data. This can be highlighted in situations whereby diagnosing clinicians remain firm in their decision, despite diagnostic evidence and/or autopsy later contradicting their initial opinions.
Confirmation bias tempts us to assess or test specifics to “rule in” or confirm our original ideas, whilst failing to test and assess other specifics which may “rule out” or come up with differential diagnoses instead. Perhaps the most dangerous of the group, there are two distinct ways in which confirmation bias can negatively affect patient care.
Firstly, upon assessing a patient, information may be sought to corroborate what we expect to find, rather than starting with a blank canvas. Upon gaining that corroboration, it becomes more likely that we may stop asking further questions due to our perception of having reached a satisfactory conclusion.
Secondly, in terms of treating a patient, opportunities to rely upon vital checks such as medication names, doses and expiry dates may be missed. By reading the details out to a colleague before showing it to them, may result in dangerous confirmation bias, should they be distracted or too busy, rather than simply requesting that they read the details on the vial to us instead.
Closing the case, and therefore our minds, in terms of diagnosis, is a common cause of clinical error. With a natural human tendency to stop looking for other possibilities once we’ve found a good solution to a problem, we risk premature closure of our differential diagnostic thoughts. So how can we avoid falling into these habits when we’re fatigued and under pressure?
1) Discussing our findings and differential diagnoses aloud may be useful in maintaining an open mind, as well as inviting in the shared knowledge and experience of a crewmate, or telephone support clinician. If fear, ego or lack of confidence prevent us from doing so, at any stage of our career, we may be doing our patients a huge disservice and putting them, as well as our professional reputations and careers, at risk.
It may be that we are working with a crewmate who seeks to mock or discredit us, should they view this behaviour as “weak” or “unconfident” or some other inappropriate judgment of our actions. Yes, this makes it undeniably challenging, in which case it may be necessary to either have a frank discussion with them about how their behaviour is affecting patient care, or simply keep the thought process to ourselves in those instances.
Even if the conversation has to be internal, in our minds, it is still possible to ensure that we purposefully step through the information and differential diagnosis options, thus maintaining safe habits that we can then bring into future working relationships when the team dynamic permits.
Even if the conversation has to be internal, in our minds, it is still possible to ensure that we purposefully step through the information and differential diagnosis options, thus maintaining safe habits that we can then bring into future working relationships when the team dynamic permits.
2) Developing a habit of seeking to contradict any provisional diagnosis we have in mind. If we remain vigilant for additional information rather than dismiss it as irrelevant to the case we have formulated in our thoughts, we are actively seeking the best answer, rather than the easiest, quickest or most impressive.
The only thing we have to prove, as paramedics, is that we can carry out our roles to the very best of our abilities. In doing so, patients receive the highest level of care possible, the organisations we work for maintain good standing within the local community, the prehospital profession gains momentum and respect within the medical world, individual reputations remain intact and are enhanced over time, and as individuals, we go home to our loved ones and sleep soundly at night, free from unnecessary work related regret or concerns.
We may be labelled as “indecisive” or “overthinkers” or “over treaters” or “stress heads" or “indecisive” or any other unkind term, but the benefits of our extra effort will always far outweigh any adhesive residue those labels leave behind.
We may be labelled as “indecisive” or “overthinkers” or “over treaters” or “stress heads" or “indecisive” or any other unkind term, but the benefits of our extra effort will always far outweigh any adhesive residue those labels leave behind.
3) Using the time we have initially upon arrival, albeit limited, to make our best decision, but keep going back to the tried and tested primary and secondary surveys we’re all familiar with for the duration of the job.
It is often considered impressive, particularly to newer paramedics, that some clinicians will attend a patient and immediately pick a diagnosis, before sticking with it unwaveringly. Whilst this may look slick and professional to some, the ever-present risk remains that vital, potentially life-threatening, information may be missed. Being able to work with a provisional diagnosis and confidently reassess for improvements, deterioration, and reactions to treatment is safe, thorough, proactive and professional at all levels.
Similarly, we can picture ourselves at home, watching a thriller, in which the lead detective has a murder suspect in their sights. We feel frustrated when they won’t continually talk to colleagues about every aspect of the case, and we start willing them to share newly gained information which may change their mind.
Once we’ve made our second cup of tea, and hit the play button to settle back in, we find it infuriating to realise that they are still fixated on the original suspect, despite new clues coming to light. Why won’t they just look around and re-assess before it’s too late?
By the time we’ve spent the final nail-biting hour on the edge of our seats, watching them arrest and charge the wrong person, we are incensed that the killer has escaped and another innocent victim had to suffer unnecessarily.
Perhaps we can apply the same to our clinical practice and adopt the ambulance detective approach to best patient care and professionalism?
First written for and published in the Australian Emergency Services Magazine Vol 17 (1) 2020 available via free subscription at https://ausemergencyservices.com.au/mag-rack/.
References
First written for and published in the Australian Emergency Services Magazine Vol 17 (1) 2020 available via free subscription at https://ausemergencyservices.com.au/mag-rack/.
References
- Kothari, S. S. (2012). Clinical errors. Annals of Paediatric Cardiology, 5 (1) 1-2. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3327005/
- Cassam, Q. (2017). Diagnostic error, overconfidence and self-knowledge. Palgrave Communications, 3 (17,025). Retrieved from https://www.nature.com/articles/palcomms201725
- Berner, E. S. & Graber, M. L. (2008). Overconfidence as a cause of diagnostic error in medicine. The American Journal of Medicine, 121 (5) S2-S23. Retrieved from https://www.amjmed.com/article/S0002-9343%2808%2900040-5/fulltext
- Elston, D. M. (2019). Cognitive bias and medical errors. Journal of the American Academy of Dermatology, 81 (6). Retrieved from https://www-sciencedirect-com.ezproxy.ecu.edu.au/science/article/pii/S0190962219322832
- Klein, J. G. (2005). Five pitfalls in decisions about diagnosis and prescribing. The British Medical Journal, 330 (7,494). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC555888/
Ambulance was booked, they sent a taxi. Hospital wa booked, I get a taxi home (my expense). I guess I would say after all of the suffering, what was the point of anyone even answering the phone?
ReplyDeleteI had significant pain. For two hours in the hospital before I left I received panadol, I was offered nurofen but it's bad stuff, so no. Australia is not the place I used to call home. WD 43.
Accompagnement médical à Paris
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