When hearing the term “medical malpractice,” many people envision a scene in which a doctor has carried out a surgery in a shoddy manner, a nurse administers the wrong medication, or a radiologist fails to report an ominous sign on a CT scan. Unfortunately, such events do indeed occur in our hospitals and medical clinics.
More frequently, however, medical negligence takes a less obvious form. Lazy or rushed presumptions as to diagnosis by doctors and stereotyping of patients by both doctors and nurses are now recognized as being at the heart of many cases involving negligent care. Such biases and presumptions affect the treater’s judgment, resulting in steps being skipped, patients’ concerns being dismissed, and proper treatment being denied. In some such cases, serious harm, and even death, is the outcome.
The medical community has become increasingly aware of the dangers of such biases and has sought to educate doctors and nurses about their dangers. However, the problem continues to be a significant cause of avoidable injuries.
This article is the first in a series that will describe the types of biases commonly found in a medical setting. The first form of medical bias that we will discuss is known as the “bandwagon effect.”
Most of us are familiar with the term” jumping on the bandwagon.” It typically describes a situation where a person adopts a position only because it is popular. In a medical setting, the bandwagon effect is seen when an initial doctor’s assessment and diagnosis are adopted by subsequent doctors without careful thought or analysis. This becomes a big problem if the first doctor’s assessment was dismissive, incomplete or poorly thought out – resulting in a patient being sent home without adequate treatment.
What follows is an example of the bandwagon effect, loosely based on an actual claim, with some facts altered to protect privacy.
A 48-year-old man went to his local ER department after developing severe pain in his upper back and tingling down his arms. Searching for an explanation, the man mentioned he had been playing hockey a few days earlier and that perhaps he pulled something at that time. The man also mentioned he attended the hospital a couple of years earlier for the same problem and, at that time, had imaging carried out.
A cursory exam was carried out by the ER specialist with some pain medication and muscle relaxants prescribed. The man was sent home with a diagnosis of muscle strain. No medical imaging was ordered and the old imaging report, easily available on the ER’s computer, was not reviewed.
That night, the pain got worse despite the prescription medication. The numbness and tingling also worsened in the man’s arms and began to appear in his legs. An ambulance took the man back to the hospital. There, a new doctor reviewed the first doctor’s diagnosis of muscle strain. The new doctor assumed the first doctor was correct: muscle strain due to lifting something days earlier. The new doctor ignored the complaints of increasing weakness and numbness and carried out no physical examination. No imaging was ordered and the old imaging report was not reviewed. His notes were even shorter than those of the first doctor. The man was once again sent home and told he had ongoing muscle strains. The second doctor also gave the man a lecture about needing to allow medications time to work before returning to hospital.
The pain, numbness and weakness continued to worsen once home. The man kept in mind the second doctor’s lecture about the need to give the medications time to work. He assumed his difficulty walking was due to the strong medication doses. Despite excruciating pain and limited ability to walk, the man waited two days before returning to the ER, this time in a wheelchair. A third ER doctor reviewed the situation and again carried out an incomplete assessment. She followed the lead of the first two doctors, diagnosing a muscle strain. The third doctor ignored the fact that the man’s pain continued to worsen despite significant and increasing prescription medication and the fact the man was no longer able to carry out simple tasks, such as getting out of a chair.
A fourth doctor finally did the right thing. The records of the previous three visits were carefully reviewed, the old imaging report was read, and a careful physical exam was carried out. The findings quickly pointed to a worsening spinal compression in an area where the old imaging identified signs of early spinal cord compression. The man was immediately transferred for emergency neurosurgery. Unfortunately, too much time had passed. The man was left paralyzed.
The Importance of Independent Assessment and Avoiding Diagnosis Bias
At play in this scenario is deference to the assessment of earlier doctors at the expense of a proper assessment – jumping on the bandwagon without careful thought. Making matters worse is a biased belief that frequent hospital visits for the same supposedly minor problem is in keeping with a person who is a drain on the system and a whiner. Such a “frequent flyer,” the thinking goes, does not need a proper workup. Instead, they can be dealt with quickly in order to free up hospital space.
This thinking ignores the fact that most people would prefer to be almost anywhere other than stuck in an ER waiting room. The drop in concern with return visits is also inconsistent with proper practice, which identifies return trips as a red flag warning for a potential uncommon but serious problem. Rather than being a situation where a doctor should let their guard down and assume the first diagnosis is correct, returns to hospital over a short time period without the expected improvement requires greater caution. It is a sign that the most common (and usually least dangerous) diagnosis may not be correct. Had proper practice occurred in the scenario described, catastrophic injury would have been avoided.
When the health care system works properly, a mistake by one doctor should be caught by the next one. Thankfully, this is often the case. The system falls apart when the doctors next in line blindly accept an earlier diagnosis instead of putting in the effort to look for what may have been missed.