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Tuesday May 10, 2016

If We Fail to Recognize Our Own Bias, We Fail Patients

I heard groaning and looked up to see a woman writhing in pain as they rolled her into room No. 1 in the rural ER where I moonlight. The groaning and squirming continued during triage, but a friend who had come with the patient seemed unconcerned and did not even look up from her cell phone.  

After a few minutes, a nurse walked over to me with an exasperated sigh, rolled her eyes, and announced the arrival of the woman, one of our regulars. Ms. Smith (not her real name) usually complained of abdominal pain, and that was the case once again. A quick review of her chart showed she had been in the ER three times in the past month for abdominal pain.

Her inpatient records included labs, plain films and abdominal CT. Some outpatient records indicated she had seen a gastroenterologist and had an ultrasound and a hepatobiliary scan. Despite her frequent visits to our ER and other sources of care, no etiology could be found for her pain.  

In ERs, patients like this are often labeled as mentally ill or drug seekers, or they are suspected of having some other secondary gain from their complaints. I am ashamed to admit that this night was no different.  

Neither the nurse nor I took Ms. Smith seriously. She was evaluated promptly with no specific findings and lab work was ordered. She was given some IV ketorolac tromethamine for pain but I was not about to "feed the bears," as we say.

To some this may sound harsh, and to those people I would say, "Good." I'm glad that your experiences have not jaded your sympathy for patients, and your first impulse is to alleviate suffering. To those who identify with this, I would also say, "Good." I'm glad to know I'm not alone in trying to maintain my humanity in the tide of opioid misuse that washes over our ERs and offices in a country where opioid-related constipation is so common that treatments for it are peddled during the Super Bowl. 

The ER is one place where we can clearly see how broken our health care system is. Patients present to the ER with complaints many of my primary care patients would not deem worthy of an office visit. Unfortunately, there is little sense of fiscal responsibility and poor understanding of appropriate utilization in our health care system, and many of these patients simply have nowhere else to go. It can be an exasperating environment for physicians and patients alike. 

Then two things I never could have predicted occurred simultaneously. The first was that Ms. Smith's urinalysis returned with large blood. The second -- and more incredible -- was that my wife texted me a link to an article she came across titled "Doctors are more likely to misdiagnose patients who are jerks(www.vox.com)."   

In one study featured in the article(qualitysafety.bmj.com), family physicians who were asked to read vignettes of clinical cases made 42 percent more mistakes on the cases of difficult patients. In a related study involving hospital-based physicians(qualitysafety.bmj.com), diagnostic accuracy was 20 percent lower for cases involving difficult patients. 

While I waited for the results of the CT scan that would ultimately identify Ms. Smith's 5-millimeter ureter stone, I read that article and began to replay her visit in my mind, ticking off all nuances that had biased my view of the case. There was her history of ER visits, my stoic nature contrasted against her more outward display of a pain I have never experienced, her friend's ambivalence, the nurse's demeanor and our personal frustrations (hers with a system that wrongly mislabels her as a possible drug abuser and mine with having patient care usurped by trying to avoid enabling drug abuse).

These biases are ever present in the physician-patient relationship and cannot be eliminated from human interaction. The error I made was that I did not recognize the bias within myself nor of those external to me. This influenced our interaction in a way that at the very least delayed appropriate care and nearly led to misdiagnosis. 

The bias had caused a misalignment between my instincts for the care of the patient and my view of the patient as a person. When I consciously considered the factors that were influencing my feelings, not only did I see the patient in a more positive light but my frustration with the situation was alleviated.

We are often taught to leave our feelings out of caring for patients, that this is part of objective care. However, I disagree. It is impossible to leave our feelings out of caring for our patients, and if we ignore the way we feel then we will make mistakes. We should instead strive to understand why we feel the way we do. In doing so we will find we can provide a higher level of care with greater satisfaction for both the patient and the physician.

Peter Rippey, M.D., enjoys outpatient family and sports medicine practice in a hospital-owned clinic in South Carolina.

Posted at 10:11AM May 10, 2016 by Peter Rippey, M.D.

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