In the past few months, two people I know almost died (one will die very soon) due to medical mistakes. Considering both of these men are well educated and live in America, in major metropolitan areas, with access to a wide variety of experts, and with very supportive family and friends, how can this happen? Tragically enough, their stories are not the exceptions. They fell victim to Anchoring Errors — judgement errors common in situations with lots of stress (e.g. emergency rooms); where many individuals are involved (e.g. a parade of doctors assigned to a patient in a hospital); where there’s inadequate time for problem solving (again, think emergency rooms); and, most importantly, there’s no built-in mechanisms to go back and re-conceptualize the problem, to re-diagnose, and to change the solution in the light of other variables or data.
Doctors make mistakes. We ALL do, all the time. But when doctors make it, the prognosis for the patients are sometimes dire. In the cases I’m about to describe, deadly…
“How Doctors Think” is an amazing book and one I have given to many of my friends and family and even to my personal physician. It describes way in which even the most dedicated medical professionals can fall into cognitive traps and end up doing harm to their very people who come to them for help. I think this should be a required reading for all future doctors. But it should also be on a list of all who go to doctors. In particular, this book provides very vivid descriptions of Anchoring Errors. (For more from Amazon, click on the book cover.)
First Case: a man in his 80’s arrives to emergency room with a bladder infection and aphasia
A friend’s father was taken into the emergency room a few weeks ago with a bladder infection. Upon arriving, the man developed aphasia — he could only speak complete gibberish. Once the antibiotics were administered for the first problem, the patient was admitted into the hospital. A few days later, a doctor (I’m specifically using the indeterminate noun: “a doctor”) visited the patient, observed the complete lack of the ability to communicate and (a new symptom) refusal to take food and water.
“The man should be released into a hospice,” a doctor pronounced. “He is trying to tell you that he is ready to move on.”
“Move on!?” the family agonized over the diagnosis. “But he is not normally like this! Our father is a university professor. He is well-spoken, well-read. And while he has been suffering from early dementia, what you see now is not the man he was just a week ago. Are you sure he is wants to die?”
While not word-for-word, the above is the gist of the conversation between a doctor and the family. This doctor has never seen the patient before in his life, he probably did just a cursory read-though the case, and made his decision on the condition of the patient based on what he was seeing in front of him: a man in his 80’s, not eating or drinking, unable to communicate, and thrashing around the bed.
It did turn out that the patient, while unable to communicate, understood ALL that a doctor was saying! The antibiotics caused constipation and he didn’t want to eat or drink because he was very uncomfortable.
A few days later, his speech has returned, his aphasia completely gone, bladder infection cured, constipation resolved, and he is happy living in his home. In the mean time, a doctor was ready to send this man to die in a hospice due to misunderstanding his symptoms! Aphasia and constipation almost caused a chain of events that could have led to this man’s death.
Case Two: a man in his early 60’s admitted into emergency room with severe malnourishment, inability to swallow, and depression
A family member arrived to the emergency room with his wife, a psychologist in another hospital. The man stopped eating some time ago — he seemed to have a problem swallowing. He recently lost his job and was depressed, his wife explained to the emergency room doctor who dully noted depression on the patient’s forms. The man was treated with intravenous fluids and released.
For many months afterward, the man was repeatedly admitted into the hospital. He was still losing weight — at over 6 feet tall, the man was down to below 120 pounds. He still couldn’t swallow, he said. He felt like his throat was abstracted, he told the doctors. And now occasionally, he had fevers.
He was diagnosed with some stomach illness to account for the fever and depression was still listed as the main cause of weight loss and food refusal — that’s what the doctors decided his feelings of “throat abstraction” were based on.
A year later, the man has only a few months to live and has finally been given a diagnosis of cancer — he wasn’t “faking” his symptoms! And while he might have had a depression (and who wouldn’t after what he has been going through?), he ALSO had a serious other medical condition responsible for fevers, weight loss, and the general malaise. He will be leaving behind a wife and two teenage sons.
Socio-technical Systems
There is very little time in an emergency room to listen to the patient. The priority is to stabilize and pass on the case to the next group of doctors. But the information written on the hospital admission forms — depressed, crazy, agitated, predisposed to death — colors all of the subsequent treatment. An early diagnosis gets carried forward and accepted as true even in the light of new symptoms and tests reports.
There was a story a few months back about a boy who died from sepsis caused by a small cut on his leg. Here’s a write up of the story that discusses the socio-technical system failure that led to his death: “High Velocity Human Factors: Adverse Outcomes in Emergency Medicine: Poor Judgment, Flawed Decision or a Fragile Socio-technical System?”