CRAIG FOSTER; KAREN FOSTER, as parents and next friends, Guardians and/or Administrators of the Estate of Brandy Foster, Plaintiffs-Appellants, v. AMERICAN HOME PRODUCTS CORPORATION, Defendant-Appellee, and BARRE-NATIONAL CORPORATION, Defendant. CRAIG FOSTER; KAREN FOSTER, as parents and next friends, Guardians and/or Administrators of the Estate of Brandy Foster, Plaintiffs-Appe
Moodle.davidson.eduQUALITY GRAND ROUNDS
Series Editors: Robert M. Wachter, MD; Kaveh G. Shojania, MD;
Sanjay Saint, MD, MPH; Amy J. Markowitz, JD; and Mark Smith, MD, MBA
The Cognitive Psychology of Missed Diagnoses
Donald A. Redelmeier, MD
Cognitive psychology is the science that examines how people
ence (in which people stop thinking when confronted with au-
reason, formulate judgments, and make decisions. This case in-
thority), and premature closure (in which several alternatives are
volves a patient given a diagnosis of pharyngitis, whose ultimate
not pursued). Rather than trying to completely eliminate cognitive
diagnosis of osteomyelitis was missed through a series of cogni-
shortcuts (which often serve clinicians well), becoming aware of
tive shortcuts. These errors include the availability heuristic (in
common errors might lead to sustained improvement in patient
which people judge likelihood by how easily examples spring to
mind), the anchoring heuristic (in which people stick with initial
impressions), framing effects (in which people make different de-
Ann Intern Med. 2005;142:115-120.
cisions depending on how information is presented), blind obedi-
For author affiliation, see end of text.
“Quality Grand Rounds” is a series of articles and com- THE PROBLEM OF MISSED DIAGNOSES
panion conferences designed to explore a range of quality issues This case begins with an unexpected and dramatic and medical errors. Presenting actual cases drawn from insti- finding—positive blood cultures in a patient who received tutions around the United States, the articles integrate tradi- an initial diagnosis of viral pharyngitis. The case does not tional medical case histories with results of root-cause analyses describe what motivated the providers to double-check and, where appropriate, anonymous interviews with the in- their initial diagnosis by obtaining blood cultures. Perhaps volved patients, physicians, nurses, and risk managers. Cases blood cultures were routinely ordered in this particular do not come from the discussants’ home institutions. emergency department, a practice that would emphasizesensitivity (few patients with bacteremia will be missed)over specificity (many results will be contaminants or “false SUMMARY OF THE CASE
positives”). Perhaps the clinician identified something in- A 65-year-old man who was followed in a dermatology tangible yet unsettling in the patient’s presentation, a phe- clinic for moderately severe lichen planus was called back to nomenon often called the “eyeball test.” Regardless of ex- the emergency department after blood cultures grew Staphylo- planation, the case exemplifies that misdiagnoses (for coccus aureus. The patient’s ultimate diagnosis was initially example, viral pharyngitis) can occur and can be corrected missed through a series of errors in diagnostic reasoning. The case is also notable for the scanty physical exam- ination recorded. Ideally, a full physical examination should be documented in all patients; however, in reality, Mr. Davis, a 65-year-old African-American man, pre- the record often omits details when patients present with sented to the emergency department of an academic medical findings that are not unusual or particularly worrisome, center and reported several days of upper back pain and gen- such as a sore throat. Indeed, charting the initial examina- eral body aches. He also reported a sore throat with odynopha- tion may seem inadequate only in hindsight, once a more gia and subjective fever. On physical examination, he was complex diagnosis is established. Such insufficient chart noted to be afebrile, with mild oropharyngeal erythema and notes frustrate many attempts to retrospectively reconstruct clear lung fields. No back examination was documented. He cases for the purposes of education, litigation, communi- received a diagnosis of an upper respiratory tract infection, cation, insight, or creating new systems for error reduction and, after blood and throat cultures were obtained, he was (as in a root-cause analysis). Scanty documentation also discharged with instructions to maintain fluid intake and to suggests poor-quality care, but the relationship between charting and other quality problems is uncertain (1– 4).
The next day, the hospital laboratory notified the treating resident, Dr. Rand, that Mr. Davis’s blood cultures were pos-itive. The organism was tentatively identified as Staphylococ- cus aureus. Dr. Rand contacted Mr. Davis at home andinstructed him to return to the emergency department imme- diately. Upon his return later that day, Mr. Davis reported symptoms identical to those listed the previous day, with pos- sible worsening of his neck and upper back pain. Improving Patient Care is a special section within Annals supported in part by the U.S. Department of Health and Human Services (HHS) Agency for Healthcare Research and Quality(AHRQ). The opinions expressed in this article are those of the authors and do not represent the position or endorsement of AHRQ or HHS.
2005 American College of Physicians 115
Improving Patient Care Cognitive Psychology of Missed Diagnoses COGNITIVE PSYCHOLOGY OF DIAGNOSTIC REASONING
Studying cognitive pitfalls in reasoning is a different Cognitive psychology is the science that examines how way to learn from mistakes. Its focus is on the recognition people reason, formulate judgments, and make decisions.
of misleading intuitions. Consider, for example, an analogy The term “science” implies that cognitive errors may be between errors in vision and errors in thinking. When peo- predictable in some situations—not the result of ignorance ple view a road surface on a hot summer day, the mirage of or the acts of a few bad performers. Instead, some pitfalls water may appear in the distance. Regardless of effort, a are sufficiently systematic that most people repeatedly person cannot help but see the optical illusion (and real make them in both routine and extraordinary situations.
problems can result if a driver acts on this impression and Thus, suspending a clinician after a missed diagnosis on abruptly changes lanes). Drivers soon teach themselves that the theory that he or she is simply a poor diagnostician their eyes can be fooled, and they use this awareness to may do little to improve future patient care. When the facilitate safer driving. The acuity of their vision does not error results from cognitive errors to which all clinicians increase; rather, drivers bring the insight gained from ex- may fall prey, a replacement clinician may be just as fallible perience to the task and override their known fallibilities.
(5). The goal, therefore, is not to demonize or deny such Similarly, studying cognitive psychology may not lead to errors in medical decision making but to understand how foolproof reasoning in all cases, but it may provide aware- these mistakes typically are made and to take corrective ness that can help avoid predictable pitfalls in specific cog- Unfortunately, the seemingly straightforward goal to learn from mistakes is difficult. Some forms of errors, such SHORTCUTS IN REASONING
as miscommunication, can be reduced through direct, un- Many errors in diagnostic thinking seem attributable ambiguous feedback and system controls (for example, to shortcuts in reasoning, tempting teachers and clinicians wrong-patient errors can generally be achieved through to believe that eliminating such shortcuts would eliminate read-backs and mechanistic constraints) (6). Selected tech- diagnostic mistakes. Yet cognitive psychology studies sug- nical procedures (for example, intravenous line insertion) gest that faulty judgments arise precisely because the un- offer a similar opportunity to immediately see one’s mis- derlying shortcuts are typically correct and produce the takes and improve. Learning from past diagnostic errors, desired results with a minimum of delay, cost, and anxiety.
by contrast, presents greater difficulty because the mistakes By analogy, the hot road illusion persists because shimmer- may often be too distal in time or place for the erring ing reflections on outside terrain usually, in fact, indicate clinician to be aware of them (no less to learn from them).
water. In many patients, for example, odynophagia does In the case of viral pharyngitis, past misdiagnoses may not resolve with the standard treatment for pharyngitis (for come to light at all (for example, the true diagnosis of example, fluids and rest). Moreover, extensive deliberation sinusitis is never established) or the patient may return to for each case could induce substantial delays or excessive see a different clinician. One might argue that the second testing. Rather than discarding the shortcuts that serve well clinician could learn from the mistakes of the first clini- in the main, clinicians might be better served by recogniz- cian, but such cases are often obvious only in retrospect, ing the potential diagnostic hazards that arise from their thus limiting the lesson (for example, florid Candida reliance on specific shortcuts in reasoning and override esophagitis is easy to diagnose once conservative therapy has failed and the condition has progressed).
Bayesian reasoning is an alternative way to learn from THE CASE, CONTINUED
mistakes by numerically expressing uncertainty as a proba- Mr. Davis’s medical history was notable for Hodgkin dis- bility for each decision point. Its main strength is to pro- ease, which was diagnosed 10 years earlier as stage IIA, after vide a language and logic for considering potential diag- the patient had presented with cervical lymphadenopathy. He noses by using numerical representations of the relevant received combined-modality treatment with radiation and uncertainty. Its primary limitation is a lack of reliable data chemotherapy, with no suggestion of recurrence during follow- to characterize unique patients or, even when such data are up. His oncologist regarded him as cured. available, the complex process of interpreting subtle inter- In addition, the patient had a long history of moderately actions. In this case, for example, the clinician’s subjective severe lichen planus, for which he was followed in the derma- opinion of the probability of viral pharyngitis was not re- tology clinic. Over the years, he had used various therapies, corded and the patient’s objective probability of viral phar- including over-the-counter creams to reduce pruritus, topical yngitis was not known. Hence, a discrepancy between per- steroids, and phototherapy. He had been intermittently non- ception and reality that would indicate faulty judgment is adherent with follow-up and treatment recommendations, and impossible to detect, let alone correct. More generally, his pruritus had worsened in recent weeks. Bayesian reasoning may replace faulty judgment with ac- On examination, his face was flushed and he appeared to curate data, but the clinicians in this case (like so many of be experiencing mild discomfort (which he attributed to neck their peers) did not use the more numerical approach.
and back pain). His temperature was 36.9 °C. The remaining 116 18 January 2005 Annals of Internal Medicine Volume 142 • Number 2
Cognitive Psychology of Missed Diagnoses Improving Patient Care vital signs were blood pressure, 170/90 mm Hg; heart rate, 98 of intense pain and stormy weather and formulate an idea beats/min; and respiratory rate, 17 breaths/min, with oxygen that the weather led to the pain. The association is com- saturation of 97% on room air. He was alert and oriented, pelling, so they may forget pain that occurred on a fair day with no abnormalities of cranial nerves II to XII. His neck and scrutinize future days with a predilection to confirm was supple with full range of motion. His oropharynx ap- the pain–weather link. As a result, people become con- peared normal, without pharyngeal erythema or exudate. His vinced of a relationship, even though studies find no con- lungs were clear, and a cardiac examination revealed no mur- sistent objective correlation (10). In this case, the clinicians murs. His abdomen was soft and nontender, with no hepato- may have set their impression around their initial tentative splenomegaly. There was no warmth or swelling of the joints, diagnosis of pharyngitis and become cognitively mired and his back examination was described as unremarkable. there, even after the back pain persisted and the positive Skin examination was notable for scaling and erythema- tous papules on the wrists, as well as hyperpigmentation and The case may also illustrate a third shortcut in reason- hypertrophic plaques on the anterior legs. Scattered excoria- ing that highlights how people confront complexity. The tions on the arms and trunk were consistent with the patient’s concept is called a framing effect, in which people tend to recent pruritus. The patient had no needle-track marks sug- come to different decisions depending on how information gestive of intravenous drug use or peripheral signs of endocar- is presented, or framed (11). A classic demonstration of ditis. The results of laboratory tests obtained at the time were framing effects is a study in which participants were asked as follows: leukocyte count, 9 ϫ 109 cells/L; hematocrit, 0.40; to choose between surgery and radiation for lung cancer platelet count, 190 ϫ 109 cells/L; and sodium level, 133 treatment (12). The outcome data appeared in a “mortality mmol/L. Urinalysis showed 3 to 10 erythrocytes per high- frame” for half of the participants (for example, “10% power field, with 6 to 10 squamous epithelial cells per high- chance of dying”) and a “survival frame” for the other half (for example, “90% chance of surviving”). Otherwise, bothgroups received identical information. The main findingwas that respondents’ decisions to elect surgery increased HEURISTICS
from 58% to 75% when the information was framed in Cognitive psychologists refer to shortcuts in reasoning survival rather than mortality terms. Through framing ef- as “heuristics,” of which the availability heuristic is a prime fects, small changes in wording alter decisions about man- example. Specifically, the availability heuristic leads people to judge likelihood by the ease with which examples spring Substantial skill is required to both collect clinical to mind (7). A classic demonstration is to ask people findings and frame them correctly. Improperly framed data whether the English language has more words that start often underlie provider-to-provider miscommunication with the letter “r” or more words that have “r” in the third (for example, when the emergency department labels a pa- position (8). Because people find it easier to retrieve words tient as having pneumonia by framing the presentation as starting with “r” (for example, “red”) than words with “r” “fever, shortness of breath, and cough,” and the accepting in the third position (for example, “car”), they incorrectly physician does not consider pulmonary embolism despite believe that there are more of the former than the latter clear lung fields that are evident on a chest radiograph).
(the actual ratio is about 1:2). Estimating the likelihood of Even without provider-to-provider communication, clini- a diagnosis with ease of recall is much more convenient cians may miss the diagnosis because they frame their own than systematically collecting and memorizing probabilities interpretation of cases and thereby do not consider alter- from a rigorous epidemiologic study. Furthermore, the native explanations. This patient, for example, could be shortcut in reasoning is often appropriate, since familiar legitimately framed as “pharyngitis, myalgias, and blood diagnoses tend to be those that are frequently encountered.
cultures positive for Staphylococcus” (which might lead the In this case, the clinicians may have attributed the patient’s clinician to suspect a viral illness and contaminated blood upper back pain and myalgias to viremia (without suffi- cultures) or “fever, back pain, and hematuria” (generating a ciently considering other causes) because such an associa- different diagnosis list, including hypernephroma, lupus tion is a familiar experience that comes easily to mind.
A second shortcut in reasoning—the anchoring heu- ristic—may also have occurred. This heuristic leads peopleto stick with initial impressions once they are solidly THE CASE, CONTINUED
formed (9). Doing so is far easier than integrating the sen- A chest radiograph revealed a tortuous aorta, a normal sitivity and specificity of every new finding encountered.
cardiac silhouette, and no pulmonary infiltrates or effusions. However, the anchoring heuristic is fallible because it con- Plain films of the cervical and lumbar spine showed degener- flicts with the scientific principle of checking for discon- ative changes but no acute fractures or lesions that might in- firming evidence. A classic demonstration of the anchoring heuristic is to ask people with arthritis whether their pain is Mr. Davis was hospitalized and started on a course of related to the weather. Many people can remember 1 day empirical vancomycin, which was replaced with intravenous www.annals.org
18 January 2005 Annals of Internal Medicine Volume 142 • Number 2 117
Improving Patient Care Cognitive Psychology of Missed Diagnoses nafcillin when cultures identified methicillin-sensitive S. au- when confronted with an apparent authority that may be human (for example, an assertive colleague) or technolog- On morning rounds the next day, Mr. Davis’s inpatient ical (for example, an objective test result) (16).
physician, Dr. Douglas, noted a new murmur, a II/VI holo- The general pattern at this point exemplifies a partic- systolic murmur heard best at the apex. Dr. Douglas ordered a ular form of anchoring bias, sometimes denoted as prema- transthoracic echocardiogram. A subsequent chart note from ture closure, which is characterized by a reluctance to pur- the same physician states “no murmur today; change from sue alternative possibilities once a commitment is made yesterday is no longer appreciated.” Transthoracic echocardi- (17). Premature closure can be paradoxically more compel- ography performed later that day showed no valvular lesions or ling in situations where several options are available. When just 1 alternative is available, generally it will be checked; Mr. Davis’s symptoms improved, and, after 4 days of when many alternatives are available, the inclination is to intravenous antibiotics, he was discharged to complete a do nothing. A classic demonstration of premature closure 2-week course of oral dicloxacillin. The presumptive diagnosis when confronted by excess choice involves a hypothetical was staphylococcal bacteremia secondary to excoriations from patient with hip pain being considered for orthopedic sur- his chronic dermatologic condition. He was also given an ap- gery (18). Half of the participants were told that the pa- pointment to see his primary care physician in 3 weeks and to tient had not tried 1 medication (ibuprofen). The other have surveillance blood cultures drawn at that time. Dr. half were told that the patient had not tried 2 medications Douglas felt that the transthoracic echocardiogram ruled out (ibuprofen and piroxicam). Clinicians decided to forego endocarditis, especially in light of the fact that Mr. Davis medications completely far more often (72% vs. 53%) reported feeling better, remained afebrile, and had a plausible when 2 options were available rather than just a single option. Apparently, the difficulty in choosing between ibu-profen and piroxicam caused some respondents to give upon both medications. For this case, premature closure may THE NEXT ERROR IN REASONING
explain the lack of a thorough search for a nidus of S. At this point in the patient’s course, the clinicians set- aureus since so many alternative possibilities were available tled on their final diagnosis as sufficient to fully explain the (for example, osteomyelitis, endocarditis, and perinephric situation—specifically, S. aureus bacteremia without ab- scess formation. The team apparently felt that the negativetransthoracic echocardiogram, coupled with the patient’sresponse to antibiotic therapy, ruled out endocarditis. In THE CASE, CONTINUED
addition, the negative plain films of the spine seem to have Mr. Davis saw his primary care physician as scheduled. removed the possibility of osteomyelitis in their minds.
Although he reported that his symptoms had initially im- Beyond these 2 exclusions, the clinicians generated a proved, his generalized fatigue and neck and back pain had pathophysiologic explanation for the patient’s signs, symp- recurred, and he now felt tingling sensations in his fingers and toms, and laboratory findings—namely, S. aureus bactere- had difficulty urinating. He was not admitted, but laboratory mia secondary to excoriations. This creative and coherent tests were ordered and he was sent home. One of 2 surveillance stream of reasoning far exceeds the powers of even the most blood cultures returned positive for S. aureus, so Mr. Davis advanced existing artificial intelligence program and under- was again called at home and referred to the hospital (this scores the irreplaceable role of clinicians’ powers of reason- Mr. Davis again received empirical vancomycin (pending In creating a coherent theory of the case, however, the susceptibilities) and underwent urgent magnetic resonance im- clinicians also downplayed several dissonant notes. Staph- aging, which showed changes consistent with an epidural ab- ylococcal bacteremia in an elderly patient who does not scess and osteomyelitis at C6–7 accompanied by spinal cord have diabetes mellitus is unusual and justifies some recon- impingement. Decadron was added to his medications and sideration. Lichen planus leading to bacteremia is also un- neurosurgery staff was consulted. A second transthoracic echo- usual and leaves unexplained why the situation had never cardiography performed during this hospitalization again developed previously. Moreover, the clinicians seem to showed no valvular lesions or vegetations. Mr. Davis was re- have relied on negative findings on 2 diagnostic tests (echo- luctant to undergo transesophageal echocardiography, and the cardiography and the plain films of the spine) that both physicians did not insist since he would receive prolonged an- lack the sensitivity for their corresponding target diseases tibiotics for his osteomyelitis anyway. (endocarditis and osteomyelitis, respectively) to truly ex- Mr. Davis declined the surgical intervention that was clude those possibilities in any patient with more than a recommended by the neurosurgical consultant and the attend- tiny pretest probability of the disorder (13–15). The ap- ing physician, and he elected instead to receive medical treat- parent over-reliance on diagnostic technology results (and ment only, with steroids for the spinal cord compression and a underappreciation of technology’s limitations) may be akin 6-week course of intravenous cefazolin. At the last follow-up, to blind obedience, which leads people to stop thinking he reported some persistent paresthesias and mild weakness of 118 18 January 2005 Annals of Internal Medicine Volume 142 • Number 2
Cognitive Psychology of Missed Diagnoses Improving Patient Care Table. Selected Pitfalls Leading to Missed Diagnoses and Corrective Strategies
Pay attention to base rates: “If you hear hoof beats, think about horses not zebras.” patient dies unexpectedly, what would it befrom?” Deliberately consider from another angle: “Let’s play devil’s advocate . . .” Tactfully reconfirm human work (in case of human authority); assess test accuracy (incase of technology) Give consideration to extremes: “What’s the diagnosis that I don’t want to miss?” his arms but no constitutional symptoms. Surveillance cultures example, framing effects can be construed, in hindsight, as on 3 subsequent occasions have been negative. the failure to document a diligent clinical assessment. Yetframing is indispensable to succinct and coherent commu- USING FOLLOW-UP TO OVERCOME COGNITIVE
nication. Insights based on cognitive psychology, arguably, can provide versatile and practical corrective strategies, ALLIBILITIES
such as the reminder to examine cases from alternative Follow-up may be a feasible strategy to prevent cogni- perspectives. By adopting such corrective strategies, clini- tive shortcuts from causing harm, since it allows clinicians cians can strive to intercept their own errors and activate to reconsider the entire picture from an alternative perspec-
tive (Table). For example, follow-up may offset the avail-
robust solutions. In fact, far from discarding the shortcuts ability heuristic by providing an opportunity to verify with in reasoning, the seasoned clinician simply adds safeguards legitimate sources, such as MEDLINE; may mitigate the to minimize reflexive decision making in nuanced situa- anchoring heuristic by providing more distance from initial tions. For instance, coming to the emergency department, impressions; and may counteract premature closure by al- especially if the patient has access to any other site of care, lowing the clinician to reconsider the case when he or she might be a flag to consider a more serious condition than is less fatigued. Many specific corrective strategies also have direct analogues to popular clinical maxims. Diligent fol- Ideally, scientific evidence would eliminate the uncer- low-up is no panacea for mistakes in reasoning, but it al- tainty that leads to missed diagnoses in medical practice.
lows for corrective intervention for the patient at hand and However, perfect knowledge of relevant probabilities is un- the opportunity to learn from mistakes for the benefit of likely, given the expense and delays in gathering medical information. Even if patients never declined any recom- The caveat to follow-up is that it requires appropriate mendation, it is not realistic to order magnetic resonance timing because some clinical problems are irreparable if imaging in every case. Notwithstanding swift Internet ac- they are delayed too long. When timed correctly, follow-up cess to the medical literature, the principles of evidence- provides clinicians with all the joys of lucky hits (for ex- based medicine are not universally practiced. Moreover, ample, cases in which the shortcut in reasoning proves exuberant testing and exhaustive combing of the literature correct and the physician seems brilliant). In addition, would probably generate an abundance of false-positive re- properly timed follow-up can make failures seem reason- ports and conflicting data that would increase—rather than able and anticipated (for example, by declaring “that’s ex- decrease—the cognitive load on clinicians. In the future, actly why I scheduled you for follow-up—I was worried therefore, clinicians will continue to use shortcuts in rea- that something else was going on”). Furthermore, fol- soning, to experience them as double-edged swords, and to low-up is high in patient satisfaction, relatively low in cost, benefit from strategies that mitigate the potential harms.
and congruent with the strongest traditions in medicine.
Indeed, the general failure to follow up is the root cause From the University of Toronto, Institute for Clinical Evaluative Sci- that allows cognitive errors to sometimes run amok in hu- ences, and Sunnybrook and Women’s College Health Sciences Centre, A conventional summary of this case might stress “never forget osteomyelitis” and emphasize the need for a Acknowledgments: The author thanks Tracy Willson for administra-
more exhaustive history and examination. A cognitive psy- tion support, and Chris Denny, MD, MSc; Edward Etchells, MD, MSc; chology review, in contrast, focuses on being aware of the Damon Scales, MD; Steven Shumak, MD; and Matthew Stanbrook, shortcuts in reasoning that prevail in decision making. For MD, PhD, for commenting on drafts of this manuscript.
18 January 2005 Annals of Internal Medicine Volume 142 • Number 2 119
Improving Patient Care Cognitive Psychology of Missed Diagnoses Grant Support: By the Canada Research Chair in Medical Decision
Sciences, Error Management Unit of Sunnybrook and Women’s College 6. Chassin MR, Becher EC. The wrong patient. Ann Intern Med. 2002;136:
Health Sciences Centre, and Canadian Institute for Health Research.
These funding sources had no role in the design, conduct, or reporting of 7. Tversky A, Kahneman D. Availability: a heuristic for judging frequency and
this project. Funding for the Quality Grand Rounds series is supported probability. Cognitive Psychology. 1973;5:207-32.
by the California HealthCare Foundation as part of its Quality Initiative.
8. Tversky A, Kahneman D. Judgment under uncertainty: heuristics and biases.
The authors are supported by general institutional funds.
9. Bar-Hillel M. Compounding subjective probabilities. Organ Behav Hum Per-
Potential Financial Conflicts of Interest: None disclosed.
10. Redelmeier DA, Tversky A. On the belief that arthritis pain is related to the
Requests for Single Reprints: Donald A. Redelmeier, MD, Sunny-
weather. Proc Natl Acad Sci U S A. 1996;93:2895-6. [PMID: 8610138] brook and Women’s College Health Sciences Centre, Room G-151, 11. Tversky A, Kahneman D. Rational choice and the framing of decisions.
2075 Bayview Avenue, Toronto, Ontario M4N 3M5 Canada; e-mail, Journal of Business. 1986;59:S251-78.
12. McNeil BJ, Pauker SG, Sox HC Jr, Tversky A. On the elicitation of pref-
erences for alternative therapies. N Engl J Med. 1982;306:1259-62. [PMID:
13. Daniel WG, Mu¨gge A, Martin RP, Lindert O, Hausmann D, Nonnast-
Daniel B, et al. Improvement in the diagnosis of abscesses associated with endo-
1. Solomon DH, Schaffer JL, Katz JN, Horsky J, Burdick E, Nadler E, et al.
carditis by transesophageal echocardiography. N Engl J Med. 1991;324:795-800.
Can history and physical examination be used as markers of quality? An analysis of the initial visit note in musculoskeletal care. Med Care. 2000;38:383-91.
14. David R, Barron BJ, Madewell JE. Osteomyelitis, acute and chronic. Radiol
Clin North Am. 1987;25:1171-201. [PMID: 3313512] 2. Sulmasy DP, Dwyer M, Marx E. Do the ward notes reflect the quality of
15. Sox HC, Blatt MA, Higgins MC, Marton KI. Medical Decision Making.
end-of-life care? J Med Ethics. 1996;22:344-8. [PMID: 8961119] Boston: Butterworth-Heinemann; 1988:67-100.
3. Romm FJ, Putnam SM. The validity of the medical record. Med Care. 1981;
16. Cialdini RB, Goldstein NJ. Social influence: compliance and conformity.
Annu Rev Psychol. 2004;55:591-621. [PMID: 14744228] 4. Fessel WJ, Van Brunt EE. Assessing quality of care from the medical record.
17. Bastardi A, Shafir E. Nonconsequential reasoning and its consequences.
N Engl J Med. 1972;286:134-8. [PMID: 5007152] Current Directions in Psychological Science. 2000;9:216-9.
5. Redelmeier DA, Ferris LE, Tu JV, Hux JE, Schull MJ. Problems for clinical
18. Redelmeier DA, Shafir E. Medical decision making in situations that offer
judgement: introducing cognitive psychology as one more basic science. CMAJ.
multiple alternatives. JAMA. 1995;273:302-5. [PMID: 7815657] 120 18 January 2005 Annals of Internal Medicine Volume 142 • Number 2
APPENDIX: QUESTIONS AND ANSWERS FROM THE
feedback from that error. Whereas everybody else who cuts us CONFERENCE
off, we’re painfully aware of, so that a lifetime of experience Dr. Lee Goldman, University of California, San Francisco creates this impression that we truly are better than average driv- (Moderator): You’ve made the point that follow-up will give you ers. The feedback of our mistakes often doesn’t get back to us, a second chance, which suggests that we can learn and be open to because people are afraid to report to us what we’ve done wrong.
new information. From your studies, is there any data as to how So that’s why after every talk I’ve given as a visiting professor often this actually occurs versus how often these heuristics persist here, I’ve searched out the chief resident and asked her, “How am in such a way that you could have follow-up forever but never be I doing and what am I doing wrong?” You know, it’s been kind of awkward for her to give feedback. She’s been polite, so a lot of Dr. Redelmeier (Discussant): The evidence shows that short procedures, such as a lecture like this, are awfully limited in what A rheumatologist: I think follow-up deserves special emphasis they can do. One of my mentors, a man who won a Nobel Prize because many of us, as I like to say, make the same mistake over in economics for a great deal of this work, tells me that he still and over again and call it “experience.” So follow-up done cor- falls prey to every one of those cognitive illusions, so if they can’t rectly allows us not only to learn from our mistakes but also does be beaten out of Daniel Kahneman, I don’t think they can be something else, and that is to see the natural history of disease in beaten out of the rest of us—nor necessarily should they, because this age of technological pervasiveness, given the uncontrollable these things usually work so well. What can be beaten out of us, urge to do a lab test or a high-tech procedure.
though, is this enormous sense of arrogance. In particular, I think Dr. Redelmeier: I agree totally. This is particularly true when adding in a spice of humility allows the opportunity for both the length of time for the encounter is shrinking, so that you no circumspection and perhaps error interception. We all know that longer have half an hour with a patient, you’ve only got 5 min- our eyes can play tricks on us, so that’s why we double-check and utes. Then you maybe only have 2 minutes worth of work time, use assistive technology, such as eyeglasses.
so that you then ask the patient to come back next week. In a Dr. Goldman: Do you have any reflections on how second 5-minute encounter, you can’t possibly get it right, so you must rely on a follow-up. In terms of the role of technology, I think Dr. Redelmeier: Second opinions, and the opportunity to that technology is a great big help. I’m a great fan of computer- view things from an alternative perspective, can be remarkably ized lab reports and entries, but technology is a wonderful assis- helpful procedures, particularly for framing effects. But the opin- tive device, never a panacea. We all have wristwatches, yet we’re ion truly has to be independent. It can’t be groupthink, as is all all late for many, many sorts of things. Watches don’t solve the too common in command structures. But, with framing effects in problem even if they do go a big way to helping people out.
particular, there is some evidence that by suitably viewing things Dr. Robert M. Wachter, Quality Grand Rounds Editor: One from community perspectives, it can help with some distortions.
A rheumatologist: One of the things I thought I heard you aspect of the case that struck me is that you essentially have 2 say is that misdiagnoses are not events from which you can learn, errors: The initial doctor says viral pharyngitis, which then gets but if I look back at my own career, in fact, the most effective replaced by the finding of Staphylococcus bacteremia; then, after learning that I have done has been from my mistakes. In fact, some work-up that was probably inadequate, the diagnosis of when you were talking, you described a number of events that osteomyelitis is missed. Do you think the finding of an initial zig were mistakes from which you obviously learned a great deal. I’m decreases the chances that you will then find the second zag, not advocating making mistakes in order to learn, but I disagree because we are limited in how many surprises we are capable of that we don’t learn a lot from those mistakes that happen.
Dr. Redelmeier: I think it’s a great point, and certainly I Dr. Redelmeier: Yes, because of the exhaustion factor. We learned a great deal from those mistakes. Sometimes you can don’t really know what’s going on, and we still don’t have the learn the wrong message, of course. What I want to emphasize is final word on this patient, right? For all we know, there may be that we make so many mistakes that we’re oblivious of, that we some sort of IV drug use going on in the background or some get lulled into a false sense of security. A classic example is that other process that we are yet to see—Mother Nature has no 90% of people believe that they are above-average drivers in skill.
mercy. Just because we’ve identified and rectified the first 3 mis- Of course, that is contrary to the laws of statistics. The genesis of takes doesn’t mean that mistakes 4 and 5 aren’t out there as well.
the misconception, though, is that every time we inadvertently And it’s not just the zigs and the zags, it’s all these red herrings cut somebody off, we’re oblivious of that fact. We never get W-16 18 January 2005 Annals of Internal Medicine Volume 142 • Number 2
●Perspectives on the Integration of Music Informatics, Performance and Aesthetics● Room C113, Aalborg University Esbjerg, Niels Bohrs Vej 8, 6700 Esbjerg, Denmark ● 12:30-13:00 The Universatory: A Presentation. Jens Arnspang, Professor, Medialogy, Aalborg University Esbjerg ● 13:00-13:30 Presentation of (1) The Research Program The Aesthetics of Music and Sound - Cro