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Carolyn Thomas recently had a heart attack that was misdiagnosed. (Geoff Howe for The Globe and Mail/Geoff Howe for The Globe and Mail)
Carolyn Thomas recently had a heart attack that was misdiagnosed. (Geoff Howe for The Globe and Mail/Geoff Howe for The Globe and Mail)

When doctors make bad calls Add to ...

Your doctor steps into the room, and already she has made a preliminary scan: your gender, your weight, your demeanour. She may have glanced at the chart with the nurse's note and be considering two or three diagnoses, suggests Harvard medical professor Jerome Groopman, the author of How Doctors Think. It takes doctors, on average, 18 seconds before they interrupt a patient, which means facts in a patient's history are often missed.

Be as specific as you can about your symptoms. Write the details down if you need to keep them straight. Make sure you know your medications and the amounts you are taking, so the doctor doesn't have to spend time figuring it out based on your “little white pill” description. And definitely don't complain about how long you have been waiting – this just wastes your appointment time.

The assessment

Doctors' minds, full of medical facts, can fall prey to several common cognitive traps, assuming, for instance, that the fit guy in running clothes is too healthy to have a heart attack. They may glance at a previous doctor's finding and accept it without really questioning it – diagnosis momentum. Or they may be waylaid by “premature closing” – stopping searching for another answer too early, or missing details that would dispute their conclusion.

Dr. Groopman says to ask questions that prompt your doctor to consider alternatives: What else could it be? Could two things be happening at once? Is there anything in my exam or test results that may contradict your working diagnosis?

Sendoff and follow-up

Your doctor has given you his diagnosis; her mind is already drifting to the lineup of other waiting patients. Make sure you understand clearly what warning signs to watch for after leaving the doctor's care, and what you should do if your symptoms don't improve.



EXPERIMENT: THE SUCCESS OF FAILURE

The argument that discussing medical mistakes more openly would make doctors better at saving patients found some scientific support in an interesting Toronto study published last fall.

In a computer-simulated experiment, 35 doctors were presented with a series of 64 patients having a “heart attack” in an emergency room. The doctors were given a short, six-point history for each patient, and two fictional drug treatments. To know which drug worked best for which patients, they would have to experiment; they had to decide which drug to use within 10 seconds. Based on their choice, the computer would flash “success” or “failure” to say which patients survived.

As a group, they didn't do very well. Only nine of the 35 doctors figured out the proper treatment pattern: Drug A worked better for patients with diabetes, and less well for those without; Drug B was the opposite.

Using fMRI scans, the researchers found that the physicians who failed the test showed more activity in their frontal lobe when the treatment worked; the small group of physicians who passed, however, had busier frontal lobes when their treatment failed.

In other words, says Jonathan Downar, a psychiatrist at the University of Toronto and lead author of the study, the doctors who learned more quickly were the ones who paid the most attention to the times when they messed up.

By focusing on their failures, the doctors had avoided a confirmation bias: They had not assumed that because they danced and then it rained, that their dance had caused the rain. Through a process of “disconfirmation,” Dr. Downar explains, “the only rules you are left with are the ones that stand the test of time.”

Being right may be just a distraction. For diligent fact-finding, in medical settings and everywhere else, the question to ask should be, “How can I prove myself wrong?”



Erin Anderssen is a Globe and Mail feature writer.

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