As a female physician, I found the gender bias of male colleagues not surprising, but disheartening. I went to med school 45 years ago, and we're still fighting the same prejudice. Sad.
1
I enjoyed this article. Confirmation bias and Availability bias are the bane of my existence and I have to be aware of them and very consciously avoid them as I go from patient to patient. Similar presentations do NOT always mean similar diagnoses and it is very easy to get trapped in the “obvious” diagnosis and forget to consider the correct one.
However, I don’t agree with the analysis of left-digit bias. Many diagnoses and treatments are guided by cutoffs in lab and test values. The cutoffs are arbitrary but as long as we are teaching “evidence-based medicine” we have to pay attention to these guidelines to help define consistent care of our patients, even when it seems arbitrary.
Our biggest bias seems to be how we listen (uncritically) to people we call "Doctor".
2
@bellcurvz I agree but patient age is also a issue
40 year career as an interventional cardiologist I applaud this article. I remember being struck by realizing this bias when beginning my career as I observed other Doc's. Some were so adamant on one approach based on a recent negative experience. I analyzed by own thought processes with decision making and realized my initial thoughts were shaded by bias but I would recognize this and put them aside and analyze the risk/benefit for each patient. The initial bias thoughts never go away, it's human nature, so diligence is required to put them aside.
Age bias though is a bit different. Major surgeries should be carefully scrutinized in the elderly, a group I'm joining myself now, as recovery and length of life are critical factors when focusing on "first do no harm" in this group.
6
I recall a time as a medical student when I was doing a pathology rotation at a major university teaching hospital. Before me in the morgue laid a healthy-appearing, middle-aged black man with several surgical tubes emanating out of his chest. The story was that he died while undergoing a heart valve transplant. We had no (paper) chart before us to rely upon for his history. The “teaching” I received from not just one, but from several doctors, was that this “transfer from the local county hospital” likely had a damaged heart valve from IV drug use causing an infection known as endocarditis. These doctors proceeded to look at his arms for signs of needle tracks, but there weren’t any. Meanwhile, I had noticed the impression of where a wedding band had been on his swollen fingers and wondered whether he had children as I had. Turns out the autopsy revealed he died from surgical error (trochanter had dissected his aorta instead of entering lumen of vessel). So I did learn a lesson that day, though not what was “taught” me.
9
As we spend time nitpicking over the inner workings of a doctor's brain bear in mind we are handing this responsibility over to thousands of nurses being stamped out as "Nurse Practitioners" with the same authority as the "M.D." to suffer through these same flawed thought patterns. I wonder about the real import of this level of scrutiny horned out here being misplaced regarding more important issues in the way cases are analyzed and the potential for weakened diagnoses.
6
Read Inevitable Illusions by Piattelli-Palmarini and Thinking, Fast and Slow by Kahneman and How We Know What Isn't Slow by Gilovich. And do it before you vote.
1
Is there also bias against left handers, a mere ten per cent of the population?
Blind in my right eye, I had to tell, on oft-repeated visits to the eye doctor, the same technicians it's useless to begin their examinations with my right eye, which they are conditioned to do with normally sighted individuals.
Wonderful, honest article . . . very much in line with why I have kept my subscription to the NY Times Science News.
The real issue this article exposes is the AUTOMATIC THINK AND THOUGHT PATTERNS we humans have running.
Much can be learned by recognizing this phenomenon.
4
the art of medicine is somewhat impressionistic
3
Very interesting analysis. It is important for all of us to review our lab and other medical results, and take the initiative to ask questions of our doctors and surgeons. Any time I've done that, they've appreciated the give and take, and often provide me with much more understanding and confidence in their care.
2
Awareness of these cognitive biases has prompted efforts to reduce them in clinical decision-making. One trial studied the effect on general practitioner diagnostic accuracy of a computer program that provided “nudges” in the right direction and highlighted particularly relevant information. The trial of these so-called decision support systems, while small, found that they improved diagnosis at a relatively low cost. Another, larger study found that changing an electronic medical record’s default options for opioid prescribing — an example of so-called choice architecture — nudged physicians to prescribe fewer of the drugs.
This last paragraph is frightening - Artificial Intelligence being used to "nudge' doctors and other prescribers to "support" decision making in both diagnosis and in prescribing, wow.
Remember always that all of these computer programs, facebook, facial recognition are about collecting data, to create algorithms which computers use to subvert or override our human ability to make decisions. The programmers and scientists collecting this data and creating these algorithms have no idea where this is going, or even WHY they are doing it - other than they can.
This is our human future???
7
@Snow Wahine You missed the part about these AI systems being used to correct wrong decisions by humans. Sounds like a great idea to me. Human decision making needs all the help it can get.
5
@David But who sets up the algorithms? People. Why are they any less fallible than the clinician who actually has the patient sitting in front of her?
3
@B Lundgren Hopefully, those who create these systems consult with experts in cognitive biases and discrimination (e.g. research psychologists in cognitive and social psychology). These humans are at least far more likely than the rest to be aware of what we need to be looking out for and to conscious of checking their own biases daily.
1
WhenI was traumatizing iced we were taught do a complete physical and history. Family history, your personal history, then a couple evaluation of your current problem then the physical that mean touching and listening,. Then we did a differential diagnosis that included all the possibilities from the exam.
Next we ordered tests to R/O or confirm.We needed good indications why we are ordering the exams. This all took time.
Now ,its "whats wrong"? and then order $4000 dollars of exams and wait for the result,Maybe 20 minutes.
7
@Richard Head - the health care industry has become an extraction industry, and what they are extracting is the patient's money.
2
I began med. school at Columbia, age 15, based on a three yr. study of liver disease. But I already knew the courses so transferred to Columbia U. through HS, then did med. res. at Yale. Vallo Benjamin, the father of modern cervical surgery, did med. res. for 35 yrs. before operating. He and I talked for hours a day about its importance. Today's drs. are taught less strictly than in Peru or Cuba. When I go through symptoms, cause, treatment, they become offended but even specialists have to be taught by me. Drs. spend five minutes per patient to make more money on their 9 to 5 schedule, 9 to 4 Fridays. Prescriptions often conflict. For some reason, once one turns geriatric, the first drug is a laxative, unneeded and destroys natural peristalsis not to mention a cause of e.coli bladder infections. Pain killers are not prescribed because of the NYS Registry while the Marijuana Program separates THC from CBD, charges twice street price in cash, and uses one generic plant. Drs. are set in their ways; no research nights or weekends. Have fights with specialists who don't understand myoclonus or tilted spinal titanium plates. Do not know how to read scans and actually think one can diagnose soft tissue problems via an X-ray (it will show a black blob if 3mm or larger). Worried about student loans.
7
@Lillian F. Schwartz I dont know where or how you got your training, but nothing you've said makes much sense. (except perhaps your opiod and marijuana comments, as I have no knowledge of NY State rules.)
7
Read "How Doctors Think" by Jerome Groopman for more info on this fascinating topic.
3
I think a lot depends on looks. Show up with lots of tattos, peicerings and purple hair and you might be treated differently than the straight laced person in the next bed.
9
@Margie Anne especially if you are in your 80s
10
wow,,, this is really surprising....
1
It is interesting to think about how some of the endless graphs and guidelines might come out differently if we just changed the categories. Suppose we started breaking everything down by comparing, say, 65-75 versus 75-85, instead of 60-70, 70-80? Or what about 67-77 versus 77-87? It would just be interesting to see what the differences might be.
5
@DW Good idea, but caution: the 65+ grouping is already way overused due to the convenience of using Medicare records to group everyone over 65 as "elderly" for research purposes. I was astounded at how differently doctors treated me a week after my 65th birthday, even though I was still employed and still had the same private insurance. It was like like Cinderella's coach at midnight. Wouldn't it be great if doctors were forbidden to use the phrase "at your age"in a disparaging way? Heard it from several who were no spring chickens themselves.
13
@DW
A moving average addresses your complaint.
https://en.wikipedia.org/wiki/Moving_average
2
@Fact checking reader: Most common phrase heard from doctors: To be expected "at your age."
4
I have encountered too many doctors who seem incapable of reaching beyond what they learned in school. If the medical condition does not match their learning and experience, they're little better than witch doctors. I see this with many professions. Unfortunately, with a doctor it can impact a poor health situation even more negatively. I lost a foot to a car. I am one of .5% of amputees with muscle control in the stump. I went through several doctors before finding one who when I said I was going to move the muscle, then did so, did not respond, "Huh, your muscle just spasmed" every time after I said I was going to move the muscle. A similar incorrect response to a tendon problem led a doctor to attempt to give me a corrective device which would have worsened the issue (fortunately the OT was present and forced the doctor to "see"). Doctors must learn creativity, as pointed out in another comment, and learn to trust what their eyes actually see, not just what they've been taught to "see."
13
Point taken about left digit bias but I would also point out that you need to make some decisions based on meaningful variables that may have arbitrary cut-offs. Is driving 66 miles per hour really more dangerous than 64? Doing aggressive interventions on people in their 80's may be significantly more risky than on people in their 70's. The exact cutoff may be arbitrary but necessary.
13
@Mark Age may be a factor, but it shouldn't be the only factor by any means. Just as in younger people one 80-year-old is not like another. Age is often just minor factor in a patient's health status.
5
@B Lundgren but while aging is an incremental series of overlapping steps, many medical decisions are binary; screen or not screen, etc.
1
Circumstances alter cases they used to say.
I always leaned towards left bias when disclosing to my husband the cost of something semi unnecessary I bought, “the shoes were only around $70” when they were $79. But my bias went the other way if it was to something I was indifferent or negative, “that cable channel is nearly $80 a month!”
9
Almost all residency programs should have mandatory reading of two texts, Kahneman's "Thinking Fast and Slow" and Taleb's "The Black Swan". Unconscious bias is a very common problem in all endeavors, but in medicine, it leads to complications and excess cost.
Aside from the issue of the left digit, there are other common types of bias: Failure to appreciate that normals occur in a range, not a specific number. Failure to appreciate that tests and imaging have a limit of resolution. Failure to appreciate that a study may have "statistical significance" yet not have practical significance. Failure to appreciate that studies may be "underpowered" to address the real clinical issue with a strong recommendation.
There are six "bad words" in medicine (and in many other endeavors): would'a, should'a, could'a, presume, assume, and average. Any time one invokes these words, there should be a brief pause to think about just what one is really thinking about a problem.
For the reasons in this article and for many others not discussed, we know that the best doctors are those who have amassed a large experience, who are open to new ideas, and who constantly question their limits of understanding.
By the way, all of these considerations apply to pilots, engineers, scientists and many other endeavors.
28
@Jeff
Consider that those TEACHING these doctors who are allowed to fall into the false norms are the ones to really educate—
MEDICAL SCHOOLS and residency programs need rigorous training in helping medical students and doctors see patients as entities not just isolated symptoms...
6
@Jeff
To cut a little slack for doctors, they deal with human patients, the type example of biased irrational responses, where even measurable physiological outcomes can vary by patient mood. Most scientists and engineers have to worry only about their own biases.
9
There is another bias I feel like should be looked into further. That is their eagerness to help someone who is going through a similar situation as them as to someone who isn't. For example, a patient might have a heart condition that is similar or the same to someone very close to the physician. Would they be more inclined to help them than someone else who has a totally different condition? It would be an interesting topic to investigate. But, doctors are humans as well it is ridiculous to believe they don't have internal biases like the rest of us. With that being said unlike us they cannot let their personal biases get in the way of their job.
5
@Jessica
Especially for conditions for which existing guidellines offer at best partial relief (such as asthma, migraines, for example), a physician who suffers from the same thing is much more likely to have kept up with the research and be willing to look beyond the first page of the Merk Manual or Up to Date or what they memorized from the two hour lecture in med school, and actually try to use their own intelligence and empirical experience when cookie cutter medicine proves inadequate. They are also much less likely to say or imply that the problem would go away if the patient weren't to whiney.
4
@Fact checking reader
It's Merck.
3
The entire top-down insurance and corporate hospital/clinic administration systems are going to squeeze the last bit of the intuition, art and intelligence in medicine out of the human physicians. This by rules, protocols, time constraints, quotas, pressure and stress. You will continue to see more "errors", misses, and less individualization in treatment.
27
@Carl
... please add "and creativity" to the 3rd line, and "threat of lawsuits" to the 5th line ... thanks
21
This "Upshot" and the underlying studies cited seem outrageously generalized with regard to medical decision-making. They also completely disregard the problem that many "clinical guidelines", which physicians are directed to follow by both governmental and insurance groups put forth binary models such as treating patients ages 65-79 one way and those 80 and older a different way. In some areas it is precisely "healthcare policy" academics who introduce distorted concepts. While there are important instances of bias in medical decision-making, this piece seems unbalanced, unreasonable and self-aggrandizing. To this clinical investigator with lots of published research and extensive experience serving major medical organizations, journals, NIH and the FDA, a it seems inappropriate.
10
Another possible bias to explore is that of underdiagnosis because of the presenting "appearance" of the patient. My "evidence" is merely anecdotal, but applies despite the disparate age of the two cases I know well. A beautiful young woman, in her mid-twenties, walks -- mobility being a first-order triage factor -- into her medical appointment complaining of disturbing heart symptoms. She went to doctor after doctor, until she finally met with one who really listened to her and gave her the workup she needed, the outcomes of which resulted in life-saving open-heart surgery at the age of 27. She was clearly too good-looking and healthy-looking to have a condition usually associated with someone much, much older. My other case concerns an 83-year-old woman with multiple health conditions, who, when she put in her teeth, wore her wig, applied makeup, and dressed up for the doctor was a knock-out, looking much younger than her actual age. One of her specialists never saw her walking into his office. She was extremely hunched and crippled but looked "normal' sitting down. Her sparkling personality and her flashing jewelry, I think biased him toward underdiagnosing and overtreatment. She was already on a lot of medication, including chemotherapy. The drug he added to the list, because obviously she could tolerate it, caused her weak, already-overtaxed kidneys to fail, and she died within two weeks. Has this type of bias -- too beautiful to be ill -- been tested?
16
@Stephanie
I can relate to the first example you cite (person who looks too healthy to be ill.) Strange as this sounds (because the medical community tells people to control their weight and exercise) more than a few doctors don't understand how serious training affects the body, alters the body's response to illness, and alters how a body reacts to medication.
There's a simple solution to this which is ask the patient three questions: Do you exercise? What does that involve? Are you doing it now? I've never been asked any of those questions by a doctor or in the initial questionnaires at doctor offices. When someone who is really into exercise stops, that means there's something wrong, regardless of whether the "symptoms" meet the standards of what you'd see in the typical overweight/obese individual who doesn't exercise (i.e. 70% of the population, and probably more in the medical setting.)
As weird as this sounds, the medical community tells people to be active and control their weight, and then some doctors (specialists more than primary care doctors) essentially say you have to exhibit the same symptoms (and blood lab results, something else that can be quite different amongst exercisers) of the overweight/obese non-exercisers before you qualify as needing medical attention.
7
Bias studies like this epitomize obviousness in service of obfuscating wealth transfers.
Instead of identifying the problem, these studies invariably justify the salaries and authorities of medical managers trying to control every aspect of provider behavior - ostensibly for quality, but in reality to extract wealth from doctors and patients.
Yes, we all want unbiased and effective care.
No, we don't buy that as justification for academia producing managers that bean-counters use control providers.
In this case, doctors are like the rest of us: when alone and pressed for time, they make shortcuts. The solution is not to give them another electronic nanny/prison guard, but to give them more time and collaboration and lifelong learning.
20
Actually, extra consideration about invasive procedures for people over 80 makes sense. Major surgery for many over 80 often results in debilitation and nursing home care. If you're over 80 I urge you to receive your primary care from a geriatrician who can help you explore your values and what is most important to you in your daily life. This is crucial when you are trying to decide about invasive procedures.
13
@BA
But that was not the question.
Is there a medically significant difference between a person who is 79 and 11 months and a person who is 80 and 1 month?
9
@Eugene
Is there a medically significant difference between similarly aged people? As a Geriatrician, I would say the answer is - it depends, and the article does not do justice to this. One of the key principles of geriatric care is that the elderly are a much more heterogeneous population. So it is very possible to see people who are 79 years and 11 months going on 65 and 80 years and 1 month going on 95 - or vice versa.
18
@MKlik I absolutely agree - I see patients that are old and decrepit in their 60's and others that are playing tennis and vital in their 80's. You can't treat the age, you need to look at that individual and their condition.
17
Good to see the coverage, but please, get some editors to give it a finer tuning. It would cut some of this frustrated commentary. What jumped out at me - The examples of differences in care by ethnicity and gender, versus differences in care according to "left-digit bias" are fundamentally two different things. The first - think about it - is very (uncomfortably, even if inaccurately) close to evidence-based medicine, as is becoming clear when statistically-based artificial intelligence algorithms are used to set bail and so on. It is absolutely unfair and deadly in a society that is supposed to value the individual and must be fought against, but "evidence-based medicine" is precisely unfair in this way, and should also be questioned, while valued, in its proper place. Left-digit bias is a true mistake by any measure. But, even that, in light of recent research reported here in the NYT about how poorly older people often tolerate even minor surgical procedures (research using evidence-based medicine) makes doctors' attention to 80+ year-olds seem pretty wise.
5
I feel this article is written as if Doctors are by default immune to Biases! They are humans too.
If anything all the research in Behavioral Economics has shown is, humans are irrational , who believe they evaluate every option best just because the same ability has made this Species the dominant one, for time being.
2
@Krishna
How did you read an article describing doctors' biases as somehow suggesting doctors are immune to biases?
2
I think the point was that doctors are as prone to irrational thinking as everyone else. The challenge for all of us, regardless of profession, is to recognize and address our fallibility
1
Chronic renal failure, hypertension, type II diabetes, abdominal aortic aneurysm all fall under this umbrella as well.
1
Like the urologist who after finding a tumor on my dad’s kidney said, “And if it’s cancer you won’t be treating will you?” He’s never have said that to a younger patient, ever.
9
@Karen Not handled well but give consideration to quality of life and listen to what the elder values most. Often it's adult children forcing the elderly into treatment they don't really want.
12
I wouldn't mind these reminders of the human fallibility of MDs if fewer of them assumed that getting into medical school was proof that they are Very Very Special, and deserve to be rich.
9
While PHD researchers in ivory towers are often helpful with their contributions, it would also be helpful if they spent time with physicians and nurses at the front lines of medical care at public, VA, and crowded community clinics.
7
Two points:
1. The review did not apparently directly interview patients. So any “left-digit” bias” of PATIENTS can’t be identified.
2. The mortality graphic suggests that the “just before 80” group was a possible outlier compared to the overall change with age in younger and older ages. If in fact, the 30 day mortality rate in the before and after 80th birthday groups were not markedly affected, it suggests the decision to operate or not might not be so consequential.
Still, always valuable to be aware of unconscious biases when making significant choices.
Thanks.
Stephen Rinsler, MD
3
Interesting article. Last year I had open heart surgery to repair a thoracic aortic aneurysm. It was discovered incidental to testing for another issue. It measured 4.7. A measurement of 5 is the signal for intervention. My cardiologist chose to wait despite that my small stature and thinness increased the risk of dissection and rupture which would likely result in death. I consulted a second cardiologist who chose to consider all factors rather than the number, referred me to a surgeon who successfully repaired it.
17
How about one of the normal shortcuts that doctors take when they see your high blood pressure and order pills to cure the problem, not spending enough time to check whether the patient lifts weights, hikes, runs, does squats while waiting for the microwave, etc. My VA doctor ordered such pills for me at age 65 which almost killed me as I fainted, dropped things, and couldn't get up off the floor. High blood pressure is not a disease. It is how your body handles activity. Check it out, Doc.
9
@Jim Dwyer
Spend some time with me rounding in the hospital one day and I will show you a dozen patients with deadly consequences of untreated high blood pressure....
16
@Jim Dwyer I'm sorry you don't have a doctor who partners with you better on this issue. My blood pressure is hard to control for underlying health reasons we can't change. My doc explains why good control is important, but defines "good" as a relative value to my quality of life. He also explains that there is a lot of trial and error with different medications for different patients. I went through a period of trying dosages and meds, some were so bad I rarely got off the couch, and the doc quickly modified those regimes. Eventually we got to a good compromise of BP levels without me feeling weak or light headed...success! High blood pressure can shorten or ruin your life, but so can a medication plan that keeps you inactive and feeling bad. It's a balancing act.
4
@Jim Dwyer Uncontrolled hypertension is something that you do not want. I have taken several medications that had awful side effects-fainting, chronic horrible cough, swelling of lips and tongue, barely able to lift a foot, before finding one with few side effects. If you have familial hypertension it generally does not matter if you throw away the salt shaker. My father had hypertension -> series of small strokes->life altering dementia. And by the way he walked hard 6 miles a day in the Texas morning heat. My mother had hypertension, exacerbated by smoking-> quintuple bypass-> death followed soon. I am able to control my bp with one medication and have resisted suggestions that we add more. I also exercise daily but not for a moment do I think that 179/90 is fine because I've just finished swimming. You have to get it lower than that, even if it takes medications, or risk the consequences. Most doctors will work with you to find a tolerable medication and dosage. But you are correct-it's a process. My cardiologist is very careful and I do not perceive shortcuts. His P.A.-a different story.
2
There are different cut off ages regarding transplants, in my late husbands case, lung transplants. He was told he was “borderline” as far as his age was concerned, even though one doctor told us of a recent patient doing well, who was in his early 80’s. My husband was 67, they preferred those 65 or younger, and I honestly feel they kept putting off the basic pre transplant test so as he got older, they would round up his age to discourage our push to be put on the transplant wait list. And the greatest irony of all, told he couldn’t go on the list because of his lack of mobility, and this told after he had been told he wasn’t “sick enough “ to go on the list earlier, regardless of age, and what we had been told initially about age cutoff dates. So basically, we were “double” biased against. He had held out hope for that procedure, knowing the risks and the odds, and when the doctors took away that small glimmer of hope for just a few more years with me and our family, his decline was swift and incredibly sad.
16
As a surgeon, I can testify that all of these cognitive biases on the part of physicians are real. No surprise. But keep these issues in mind as well;
1. In the medical literature, studies of practices and outcomes are structured by groups (age, cyst size, hemoglobin level, etc). If a physician treats a patient contrary to the findings of peer reviewed research, regardless of the circumstances, they may find themselves answering to an expert witness/plaintiff attorney in a trial if there is an adverse outcome. “Why didn’t you give a blood transfusion when the hemoglobin was x.9 when the literature says that you should transfuse for x 1? Isn’t that recommended to prevent myocardial infarction?”
2. We should be so lucky that physicians are making poor decisions based on percentage point variations from standards. There are still frequent gross variations in the use of diagnostic imaging, treatment of hypertension, and decisions about operative intervention that are far from evidence based. Ignoring, of course, the tens of millions of people who have no or limited access to medical care at all.
36
What do you call the student at the bottom of their Medical school class: Doctor!
8
@bcer
Don't you call a lawyer who graduated at the bottom of her class a Judge?
5
@Piceous That's certainly becoming true in the Age of Trump
8
@bcer What is your point? Is that student any less a doctor than the one who graduated first? With the exception of those who go into research, do you really think that academic ranking is the deciding factor between a good doctor and a bad one? I've know a lot of "top half" doctors who were very good at memorizing facts, but completely unable to apply them in everyday situations, and vice versa.
2
So basically this study found that doctors are (drum roll) human.
23
What do you call the guy who finished last in his class at medical school?
Doctor. (ba dum ba)
Seriously, there are biases to which we are all susceptible. I would like to believe that professionals, in their capacity as professionals, would be aware of and able to navigate. Alas, it is not always (or even frequently) the case.
One's best defense is to ask questions and be able and willing to change doctors. That is an increasingly rare luxury. And of course, when one is in crisis, nearly impossible.
11
@Sarah What do you call a team that loses the Superbowl? "Losers," yet we understand that it must be a great team to even get to the game. If a doctor completes their rigorous education they can certainly be successful, because grades don't define the doctor completely. Things like EQ, communication skills, intuition, compassion, bedside manner, humility, stress management, ability to multitask, etc. all make a huge difference, yet may not register on imperfect grading systems.
4
As a teacher I might note that "A" students and "F students are often the same kid. A letter or number grade is only an indication not an identification of ability. Teaching different grade levels in the same class also lends itself to faulty self fulfilling notions of student age and its relation to maturity and ability. Best not to categorize too much. Tough to do in practice~
14
Doctors need to make computer assisted-decisions. There are a few (or perhaps many by now) software programs that assist doctors in arriving at a diagnosis, and recommending appropriate treatment.
Why is every other field, from finance to architecture using computer assistance at work, and doctors are still in the last century?
Could it be that we still have an unconscious Jungian belief in the “Doctor” as the “Holy Medicine Man” ?
Both, we the public, and the medical field, must reboot our thinking on this. If a computer can win Jeopardy, most certainly it could give its opinion on a patient, with the human doctor making the final decision.
It’s called “accepting assistance”, because you, doctors, are only mere mortals. No, you are not the tribes’ “holy medicine man”. Get with it, people.
14
@Lily Computers already make decisions in medicine every day. When your insurance company denies the MRI scan you want to get, who do you think makes that decision? It's not a human, it's a computer algorithm that determines that.
Be wary of what you wish for.
35
@Diana
I hadn't thought of that but it's an excellent point and illustrates another issue: too often mistakes get made because doctors have only 15 minutes per appointment which tends to force them to make decisions based on the "average patient." At a "population level" that yields the largest number of correct answers but not everyone is an average patient and statistical outliers get overlooked.
The real value in being a doctor (I'm not one) is the ability to talk to a patient and learn what unique issues/symptoms they're experiencing. AI and machine learning are of limited value in most situations because the statistical models they use by definition have difficulty dealing with unique situations.
15
@Lily Computers are making decisions already, and it won't be long before someone realizes that some of the decisions are as good as the ones that caused the Boeing 737 MAX crashes. When I use my electronic medical records system, there are diagnoses I cannot make because they are not in the system; there are pharmacies that I cannot send prescriptions to because they are not in the system (at least for now the law still allows phone or paper prescriptions - but probably not for long), and there are lab tests that are in the lab company's system but not in my system, and vice versa.
27
Another bias is that unless you present with a common side effect from medication, it is immediately assumed it is not the medication causing the issue. It might even be a side effect that is so rare, it's not listed in the info the dr has access to. That's happened several times in my family. Only one dr allowed for the possibility; she is a great physician.
40
This an example of the bias when one thinks someone else is smart if they believe what they themselves believe.
6
@Better American than Republican
"Rare" medication side effects may not be rare at all. If they didn't show up in the initial drug company sponsered research, patients are told that what they are experiencing cannot be drug related, and so it remains unreported and the reaction continues to appear to be rare whether or not it is.
The same applies to rare diseases. If doctors refuse to diagnose a particular condition because it's rare, the condition will remain underdiagnosed and appear to be rarer than it is.
4
That "left digit bias" described here is fairly unavoidable as long as we are inclined to seek and ascribe to generalized guidelines, cut-offs and categories of risk/benefit. When research indicates that procedure X is most effective on patients younger than 80, for instance, the difference in effectiveness between the patient who turned 80 yesterday and the patient who will turn 80 tomorrow is likely not significant. But that is the nature of statistics--they are most pertinent when dealing with groups (the bigger the better), and they are far less meaningful when considering an individual. Blind adherence to cut-offs may result in over-treating some and under-treating some, but that is the nature of healthcare aiming for efficiency. If I am responsible for only one patient, I can devote almost limitless time to exploring every variable before making a decision. But even then, I will sometimes be mistaken.
15
Even doctors who knows a patient for many years will rely on numerical age over other factors with which they are familiar. An ophthalmologist who operated on my aging mother four times (twice for cataracts, twice for blepharitis) kept playing with drops rather than perform glaucoma surgery because of her age. The doctor knew how well my mother healed each time; rapidly, and without complications. Patients have histories and, sometimes, physicians even know those histories. On a similar note, the nurses who come to 'supervise' our home health aide are forever pushing low-salt no-salt diets on someone with a history of falling (easily deadly become of the follow-on bed rest) yet no personal or family history of hemorrhagic stroke. Lastly, I would like to suggest that left-digit bias be put to good use: drop the last digit (which has no clinical significance) so that a 'normal' blood pressure becomes 12/8.
12
Of all the problems to work on—why would we spend our time forcing docs and nurses to divide blood pressures by 10 in order to drop the last digit?? The last digit actually does have clinical significance—this is an actual measurement in millimeters of mercury (mm Hg). There is a world of difference between a systolic blood pressure of 12 (!!!) and 120–the former is incompatible with life, the latter is considered normal.
2
I have a very common chronic illness, Hashimoto’s thyroiditis, or autoimmune hypothyroid. It affects women much more than men and approximately 10% of the population has the disease. The symptoms are exhaustion, brain fog, weight gain, anxiety, depression, food sensitivities, and concurrent autoimmune diseases. Many people are misdiagnosed because when a doctor sees a woman who is tired, overweight, having mood issues, and can’t think clearly, they tend to diagnose depression (I received that diagnosis twice.) Even if the person is understandably unhappy, that is a symptom not the root cause. I would say this is a combination of gender bias, a bias toward a “quick fix” with medication, combined with a lack of knowledge and a lack of time spent with the patient.
46
@Betsy You make an excellent point. Based on personal experience and discussions with female and male friends, I believe there is a gender bias in diagnosing depression in women, especially when depression may present as a symptom of the underlying illness. For this reason, I will never admit to my healthcare provider any symptoms that can be construed as depression because, if I do, they stop looking for anything else. Stress/anxiety is also becoming a diagnosis of convenience: my dentist diagnosed TMJ when an X-ray didn’t reveal a physical cause for the pain in my jaw and I admitted to increased levels of stress. Another dentist later found a deep abscess exactly where I had reported the pain.
13
@Betsy
Doctors are being pushed to look for signs of depression these days. Even just two years ago it was not a routine part of the medical record, today it is. The symptoms you describe are totally compatible with depression; however a good doctor will also look for hypothyroidism as part of a "routine" workup.
3
This is not rocket science. Anyone with any kind of scientific training knows how to round off a number. If a doctor cannot correctly round off age or other number, they should not be treating patients.
8
@pat It's not about "rounding off a number". It's that we are biased toward putting people in categories, which may or may not be beneficial.
Often treatment guidelines will say "<30, do X". If someone is 29.5, the guidelines say to do X. This is because the guidelines are 1) made by humans 2) trying to make sense of population data 3) trying to be prescriptive.
But maybe that 29.5 year old actually should fall into a different category than the one the doctor is working off of, for patients 28-32. But the medical world hasn't discovered that subcategory yet because the analysis wasn't done that way.
You're right, medicine isn't rocket science. It's a complicated science where experiments are difficult to perform and data are spotty. I appreciate any investigation into these biases and practices!
16
Doctors are human, just like the rest of us. My takeaway: It's always important to ask how a doctor came to a conclusion to treat in a certain manner and to follow-up to learn all we can about any condition we have or may have, as well as to get second opinions any time the condition may be serious or surgery is suggested.
13
@Barbara goo luck getting a doctor to take the time to answer your questions.
1
Love these doctor-bashing articles by authors who didn't go to medical school.
I went to medical school (U.ofP.) and did a 5 year residency in surgery. I practiced surgery for 43 years before retiring. It never was easy. In addition to the incredible amount of knowledge we must struggle through in training, we must continue with CME for our entire careers. I also had to re-study for recertification for my boards in 1986, 1996, 2006 and 2017. Think that was easy?
So, do we possibly have a bias towards older patients because they might not do as well with medicine or surgery. Sure.
Should we be constantly criticized for having normal brains? I don't think so.
22
@doc I am a medical social worker. I don't read this as doctor-bashing but rather as recognizing that even the very best doctor is human. I saw too much behind the scenes, such as doctors covering for other doctors who should have retired long before not to know that studies of how doctors make treatment choices is warranted. Smart patients will always ask questions of their doctors, too.
42
@doc Dr Jena did go to medical school - at the University of Chicago, and is a practicing physician. I agree with commenter below that this and other studies by Dr Jena and his group are not meant to be doctor bashing at all, but instead to describe and quantify patterns, beliefs, and misbeliefs about the way doctors think and the way medicine is practiced.
28
@doc
"Love these doctor-bashing articles by authors who didn't go to medical school."
(from bottom of article)
"Anupam B. Jena is a professor of health care policy and medicine at Harvard."
(from website)
https://hcp.hms.harvard.edu/people/anupam-b-jena
Anupam B. Jena, MD, PhD, is the Ruth L. Newhouse Associate Professor of Health Care Policy at Harvard Medical School and a physician in the Department of Medicine at Massachusetts General Hospital.
...He received his MD and PhD in Economics from the University of Chicago...
26
The further you stay away from doctors and hospitals the healthier you will be and the longer you will live.
12
@riley
As long as you remain at a "normal" BMI, exercise regularly, don't smoke or do illicit drugs, eat sensibly, etc.
Oh, and get checked for hypertension every so often, as it causes no symptoms ( until it has already caused your kidneys to fail/heart attack/stroke/blindness).
Oh, and get checked for diabetes every so often, because even people at normal weights can develop it.
Oh, and keep current with vaccinations so your chance of dying from influenza or pneumonia, or developing reproductive/anal/head and neck cancers ( all HPV related), is greatly reduced.
Oh, and....
28
@riley That’s about as useful as Reagan’s dictum that government isn’t the solution, it’s the problem.
10
@riley and if you DO get sick, be sure to go to the supermarket and not the hospital because way more people die in hospitals than supermarkets
13
"Left-digit bias could affect many clinical decisions. For example, patients with hemoglobin levels of 9.9 grams per deciliter may be perceived as being substantially more anemic than patients with hemoglobin levels of 10.0 grams per deciliter (the difference in the two values has no clinical significance)."
Which is why you believe an item with a price tag of $59.99 is less expensive than a similar with a price tag of $60.00 -- even as you're now asserting that you're "much too smart" to be fooled by that trick --
Well - if we are all' "much too smart" - then why do they continue to price-label items that way -- ??
Why do they call it a 99¢ Store ?
These biases are ingrained in all of us - and clever marketing strategists know how to pull the strings in just the right way --
While it's unfortunate that this ingrained bias has apparently seeped into the medical profession - it's really not surprising...
11
Always remember this!
A woman who has severe headaches is assumed to be neurotic.
A man who has severe headaches is assumed to have a brain tumor.
Each are likely to be receive treatment based on these bias.
Of course other bias may not be gender based, such as being overweight or a smoker, or being insufficiently awed by the presence of the doctor.
23
@TarsanStripes I don't know where you get this assumption from. As a family doctor I would assume nothing, but I my first guess would be that both have migraine. Migraines are much common in women than men though, and I don't think that is a bias but is a fact
2
As my current 41 year old doctor and two other doctor friends, both in their 70s have told me, you don’t have to be smart to be a doctor, just tenacious.
12
@Paulie
A medical professor friend informs me that the biggest problem today in medical school is stupidity. I think he is (partially) kidding?
1
@DW He is, partially
1
Another example: A non-cancerous cyst that was not removed because it measured only 9.7 cm and the medical profession recommends surgery only if the cyst exceeds 10 cm. Was that extra .3 cm really significant? The risks of surgery were assumed, but should we have discussed the benefits of doing surgery immediately rather than waiting, and should I have been able to make an informed decision? Definitely. Did that happen? No. And by the time the cyst reached (surpassed) 10 cm, other negative effects were at play. I had not heard of "left digit bias" until I read this article, but it all makes sense now.
23
@Sara Todd
But isn't that the opposite of left-digit bias? If it were left-digit bias, the "9" in 9.7 would have seemed more troublesome (thus influencing the doctor toward excision) than the "1" in 10.0.
What you are talking about is following guidelines. Are the guidelines foolproof, no they certainly are not, but there is a reason we follow guidelines. If the guidelines said to excise any tumor over 9.8, and yours was 9.7, you'd be saying the 9.8 was not appropriate. That just ends in discarding all guidelines, because wherever you set the cutoff, there will always be tumors that are just this or the other side of it.
3
This is why doctors should have experienced nurses at their side when examining a patient. It’s the same reason airliners require two pilots when one can fly the plane alone very easily.
9
@Paulie Nurses are immune to bias? You obviously havent worked with any.
9
@Paulie
Ahhh...such an easy solution. Pair an bias-prone physician with a bias-free nurse. Now why didn't anyone think of that!
3
@Paulie A doctor and a nurse is not equivalent to two pilots. If you really wanted to go with that analogy, you may want to suggest that doctors should have other doctors at their side when examining patients. But otherwise, go see your nurse practitioner instead. You'll do great.
2
Medicine is an art. It was when Ibn Sina would taste urine a thousand years ago in Tehran and it still is, in spite of perusing patients with all the tools we have today. It's tough to teach, tough to automate, although progress progresses.
7
@samruben
In spite of all the obstacles, including the sicker patients due to societal ills, the financial mess, the time constraints, compliance issues, the whole mess that healthcare has become in this country, even with the promise of computers and gaming more and more data, it's still an art. Some of us don't have the mindset for it.
5
If the people I went to med school when are any indication, I’m not the slightest bit surprised at these findings. Terrifying!
7
I’ve said this my whole life: doctors are only human. Having grown up in an era where doctors were always held up to near deity status, I’ve taken a lot of flack in my life for always questioning my physicians. I have found that doctors are terribly arrogant aside from being terribly biased. I truly believe part of that is because as a society we held them in such high esteem that they could do no wrong. But they are only human like the rest of us. They put their pants on one leg at a time like you and I. And they make mistakes like you and I. Except their mistakes can mean death for you and I.
14
Cognitive biases, whose number keeps increasing to over 3O now, probably have an effect on many decisions, although not necessarily as life-and-death, or pain-reducing as the ones in this article. But still maybe somewhat important.
Just think of some of our bedrock tenets, and in a number of fields, that assume we either don’t have them, or that they are insignificant. But what if they’re not? And a lot of decisions get made based on them. What if we’re very good at fooling ourselves?
In economics we are rational decision makers. In democracy we objectively sort through candidates’ positions and vote for the best one. In my students’ sociology textbook, we are the “highest” species mostly because of our intelligence.
Although these are all questionable, I’m not arguing for their complete opposites, as I see in some places, such as throwing out the pursuit of objectivity or uncritically promoting emotions without any guidelines for them.
But we need to figure out such a challenge to core beliefs. It might be possible to both put apparent opposites in proper proportion or find creative hybrids, say, “Thinking with the head and heart.” (Some would add the gut.)
We can start by taking cognitive biases seriously. And reducing the corresponding importance given to appearing confident, assertive, “winning” such as in debates, snark, spin, even the automatic default given to saying something is based on “common sense.”
They may be based on delusions—personal, social, or both.
5
I think anyone would resort to cognitive heuristics when their work week is in excess of 80 hours. Or at the end of a 30 hour shift. While this is the plight of surgical residents, attendings don't have it easy, either. I think addressing the shortage of residency spots, finding ways to allow doctors--who are humans--to sleep would greatly reduce these errors.
43
Cognitive bias does influence clinical decision making. But I think what is less studied is the impact of time constrains that lead to diagnostic momentum leading to errors. If a doctor is given 2 patients per hour instead of 6-8 does it make a difference? When I took the American Board of Internal Medicine examination I had lot more time to answer the questions (clinical cases histories) than I ever had practicing medicine.
30
Considering the number of patients encountered in the day of typical radiologist (often well over 100 ) the authors have missed an opportunity to specifically address this cohort. Multiple number of patients x number of decisions per patient divided by time spent on those decisions and a remarkable statistic is revealed = decisions/unit time (sec). Further while all the rage in the press artificial intelligence (AI) and machine learning are far from ready for prime time. IMHO current utilization rates for medical imaging not sustainable based on available staffing. The risk of making a significant error should get everyone’s attention. It’s a crisis the public is general unaware of and it is occurring nationwide 24/7/365.
20
@Radiologist Hmm . . . I didn't know most radiologists encountered patients!
3
A radiologist in my area gets 12 weeks off a year. You’d think people would be flocking to become radiologists.
1
Left-Digit Bias...if only we knew that a stent procedure should be priced at $18,999 and not $19,000 we'd be so much better off. Studies such as these are frivolous and assume that the US has a viable health care system. Let's first solve getting people access to health care that won't bankrupt them, then we can worry how its administered.
Why are we not focusing our research and studies on why Americans pay exponentially more for health care and prescription drugs in the country and why millions have no coverage at all? Instead, we are literally focusing on decimals.
There is bias in everything we do because we are humans not robots. Even robots are biased because humans created them.
10
The name says it all. I am THE survivor of my cancer type/location (in my nasal passages). Typical lifespan is a few months of agony. I am now over 7 years clean. Of note, father-in-law was a neurologist. As a cyclist, he would always check me out post crash. Before my radiation treatment (cancer was chemo resistant) an intern gives me the "standard" neurological exam but adds a suicide assessment (warranted with the expected survival rate) and an IQ test, to determine baseline IQ. As a non-naive patient, this exam terrified me. How damaging will my treatment be if you are checking to see if I will still have enough intelligence for self-care? Made it through, as I am writing this missive. Nonetheless,scaring the daylights out of patients BEFORE TREATMENT is less than reassuring.
14
I enjoy reading an empirical article grounded in facts and repeatable observation. I’ll share an anecdote: my 94 year old aunt could not get a Long Island doctor to operate on her Venus insufficiency and resultant cellulitis presumably due to the left digit. She has moved to Florida and recently completed her third procedure for this condition. Perhaps one’s comfort in providing treatment to the aged increases with frequency and opportunity.
16
@Michael
But did anyone treat her Saturnine gout?
11
@JB Huh? Venous stasis disease and saturnine gout have nothing to do with each other, although they can co-exist.
More importantly here is the question, did her 1st, 2nd or even her 3rd procedure make a difference? Or did the doctor just make more money feeding her need to "do something"?
1
@LesISmore Sadly, the later is correct. No improvement. Arguably her condition worsened after the procedures
Sure, there's some truth to this. But clinical medicine depends heavily on pattern recognition, and pattern recognition is deeply interwoven with various forms of bias, some of which are listed here. Bias, it is important to note, is not the same as prejudice; its use in this context is a reflection of how all of our minds work and process information.
Though clever and likely true, the concept of "left digit bias" is also somewhat silly, because the vast majority of errors in medicine occur due to dysfunctional, overwhelmed systems-- too many patients, not enough time, and not enough resources. Put another way, elegant esoterica like this is fundamentally out of touch with the true problems in healthcare in this country.
56
@Frank
Wish you were a full-time writer here (assuming you're not) -- this is a beautifully written, highly astute comment.
9
@Io Lightning
thanks Io Lightning
1
How about discussing the bias that comes from using the latest APP or other new tech discovery to treat their patients when researching the new tech might be lacking. A good example of that was Elizabeth Holmes and her company Theranos who claimed she could do blood tests with a tiny amount of blood for several diseases. She was, in fact, a fraud and couldn't do any accurate blood work.
10
Choice Architecture-
That phrase and that idea repulses me. That sub rosa manipulation disgusts me. Arguing that it is for the greater good only further confirms it. Treating me as a creature to be managed --as a patient or as a provider or as a voter-- is wrong.
What artificial intelligence subgroup does that put me in?
8
I’m surprised not to see the lead include the rampant and historic gender/sex biases and abuses among physicians.
Similarly, the very-often overlooked and harmful disability-phobia or strictly medical model of disability that still, in 2020, causes doctors to make egregious errors in assessing, diagnosing, treatment planning, treating, and advising patients with a disability and/or their family members.
And further, the if-insurance-won’t-cover-it-don’t-even-mention-it-as-a-treatment-option bias that prevents patients and next of kin or persons assigned medical DPOA from even knowing all the medical options — in other words, denying them true and full informed consent to treatment plans. I’ve always found it unethical (and probably illegal) for doctors to withhold information from patients/families because of the doctor’s impression or even actual knowledge of the patient’s financial situation. Doing so robs patients and families of treatment options that they might have or find ways to pay for (especially in the GoFundMe age). It also robs them and all of us of the opportunity to more fully asses insurance companies’ biased policies or possible wrong-doing and to protest and to spur effective, ethical change.
15
There are also biases on interdisciplinary teams, some of which work against the creation of such teams in the first place.
For example, physicians’ misimpressions or misinformation regarding the professional rigor, required education and training, areas of expertise, and purview and roles of other health care professionals, individually and as an entire field of practice and research.
I can’t tell you how many times, as a patient and a professional, I’ve encountered physicians who discount or are flatly ignorant of the expertise or utility of fellow (non-physician) health care workers and their professions as a whole.
Examples: referring to PT for assessing and suggesting school or workplace accommodations for a patient when OT would be the most appropriate and useful approach; or neglecting to consult either discipline. Or treating medical social workers as glorified secretaries whose job and only value is to fill out order forms for DME or call in protective services reports. Similarly, surgeons ceasing or reducing referrals to social workers or health psychologists after observing a family exiting a consulting room in (cathartic) tears — the doctor assuming the family was tearful with rage or that the tears were inappropriate responses to grief, and that the role of the psychologist or social worker was to, “make them (the family) smile” or to “get them move on already.” Or the doctor simply passing over mental health and other social-science disciplines altogether.
7
Doctors are people. They are often overworked and stressed.
A good friend of mine moved from New Hampshire to Canada. She is a Pediatrician with 20 years experience in the US. She knows she is a better doctor in Canada. She has twice as much time to spend with each patient and has 90% less paper work to fill out.
Doctors are people. Lets figure out ways to help doctors make fewer mistakes. They are not robots. The vast majority want to help people. Lets figure out ways for them to do their jobs with less stress and more accuracy
127
@Liza Or maybe a few more of you would like to come to Canada: it's not perfect but many of the worst things mentioned here are absent
8
@Liza Or maybe if we take out the endless layers of profit we could have better doctors here in the US. But now we live in the land of Greed Is Good.
7
@Liza Or maybe take on fewer patients. Give good care to fewer patients rather than jam your day with so many patients so that you can make more money as you make unnecessary, deadly, and/or costly mistakes because you're overworked and stressed, by your own doing.
2
There had been domestic trouble in my household where my husband was ordered by authorities to leave. My pediatrician had been involved because police wanted my daughter to be checked for any "healing fractures" and her doctor felt it unnecessary (which was the right call). But when I approached my child's doctor a few months later for a Lyme test because of her listlessness, he refused and said she was just depressed about her family situation. A month later I went back because my daughter was like a rag doll and had dark circles around her eyes and demanded a Lyme test, in which he reluctantly relented. A month and a half later he had not contacted me about results so I called. The nurse took a look at the files and said the doctor would call me back. My daughter had Lyme. If I had not demanded he give her a test she could have had Lyme much longer, and it would have been due to his bias about our family problems. So I do understand how this type of thing happens!
18
@C. Bernard I suspect the chance of a Lyme disease test in Florida being a false positive is much greater than the chance of actually having Lyme disease there, which is likely why the doctor did not want to do the test in the first place.
5
@SF My apologies, I should have mentioned I was living in Westchester county N.Y. at the time.
3
@SF While that is true, we have no travel history. On the other hand the numbers of Lyme disease, native to Florida, is increasing (>500 in 2019 as compared to 175 or so in 2018)
So, do you suffer conformational bias?
1
Like detectives there is a tendency to pick out a suspect immediately and spend time trying too prove him guilty rather then evaluate others. Once you decide an answer you pursue it.
DOCTORS OFTEN JUMP TO CONCLUSIONS AND FORGET TO LOOK AT OTHER CAUSES.
17
"One study found that when patients experienced an unlikely adverse side effect of a drug, their doctor was less likely to order that same drug for the next patient whose condition might call for it, even though the efficacy and appropriateness of the drug had not changed."
Sort of like putting up concrete barriers, metal detectors, and armed guards at every government building even though a bored guard with a revolver is more than enough security for most places.
6
@NorthernVirginia Also kind of like making every airline traveler take off their shoes at checkpoints forever, thanks to one failed shoe bomber.
20
Medicine has resisted the application of information science more than any other industry. I imagine that there are multiple reasons for this relative intransigence, but one of them has been resistance from physicians, who are one of the last professional groups to continue to lay claim to the notion that the "art" of their profession can't be captured in algorithms. As a recently retired physician myself, I would suggest that this is self-serving nonsense.
Big data and AI are revolutionizing the world. Physicians are humans, with all their foibles, as this article nicely demonstrates.
EMRs certainly aren't perfect, but the system that existed prior to their implementation (or, more accurately, the lack thereof) was even worse, by a long shot. EMRs weren't designed as tools to limit access to care. They were designed to provide a modern framework for provision of care. They can be used for good or bad (or both.)
EMRs do, indeed, place a burden on health care providers that they may not have experienced in the past. But they also bring many, many profound advantages. In the interest of space and time, I will not list them here.
Those who decry the appearance of algorithmically driven "cookie cutter" medicine fail to understand that with enough accurate data, AI based (self-improving) algorithms are, in fact, "better" than virtually ALL humans at making complex, objective, rational decisions.
AI is the future, like it or not. EMRs are the gateway to that future.
11
@Enigma Variation
It will get better when the patient is examined by the plexiglass bulb of an AI doc, before it gets worse.
2
@Enigma Variation
There is an "art" to medicine as patients often report symptoms in qualitative terms but there also is much science. Effective medical practice requires a physician to be able to apply both to diagnosing and treating a patient.
EMRs are a definite improvement. In integrated practices, they make sharing patient information easy and effective. What would be nice is standardization of computer formats such that EMRs can be shared (with patient approval) across multiple providers as needed.
3
@Enigma Variation The creation and implementation of EMRs is incredible lousy. Physicians and nurses in every specialty should have had a major role in determining the questions and list of responses one can check off, but they had little or no role.
Whoever devised these knew a heck of a lot more about IT than about medicine. The result is a virtually unusable nightmare.
14
It's clear the medical profession is changing and as patients, we have to decide how best to handle both the biases inherent in our treatment, and the fact that most of us are now a commodity, rather than a patient.
While I've been very lucky lately with my choice of physicians, I can see they're spending less time with me and as I age, almost all of my medical issues are now being blamed on the aging process. Some of the time, this might be the case, but most of the time, it's easier for the physician to claim it's aging and not spend the time to find the real cause of the problem.
The moment we elevated physicians to a pedestal, we relinquished some of the control for our care. They aren't gods. They make mistakes and they aren't always right. So, choose wisely and pay attention.
21
@Pamela L. Reminds me of the ancient joke: "My right leg really hurts," the old man tells his doctor. "The problem is simply age," the doctor replies.
"My left leg's the same age as the right, but *it* doesn't hurt!" yells the old man.
10
I have a new-to-me primary care doc. She comes into our consultations sits at the computer and never looks at me. First time we met, she didn't pause to introduce herself. Her eyes stay on the computer screen. It is clear that she forms many judgments about me without looking at me. She has never touched me to listen to my heart and I have a fib and heart failure.
It is not easy, not for me, to get a new patient appointment with a primary. I will. In the meantime, this Stanford doc leaves me feeling that no health care provider is paying any attention to my health needs.
OH: I have multiple and serious health challenges.
I hate sitting next to her, watching her play that keyboard, surfing the net for answers to whatever she's thinking.
Next time I see her, I'm going to ask her to not play the keyboard, to talk to me about my presenting issues and to pay attention to herself to note how she assessed me. Act like a doctor, maybe?
87
@Daffodil Honestly, I'd just find a new doctor.
28
As a medical provider, I always try to pay attention to the patient. It means more work for me at the end of the visit, but the connection you make with someone can be huge.
What patients come in for is not always at the root of their claimed illness.
The electronic record checkboxes can’t read faces or pick up on nuances that mean so much to us old schoolers. I often miss the paper charts.
I hate the coding, billing, insurance cesspool that has become our modern care. It’s all about about money for the companies, not the patient.
19
@Daffodil What are you talking about? The research shows that female doctors are always the best.
2
I have twin sons. When they were a few months old, one of them got a urinary tract infection. My pediatrician urged me to schedule him for some sort of complicated urinary tract testing, and she wasn't happy when I said I'd have to think about it. When I got home, I called my obstetrician, whom I trusted, and told him what she'd recommended. The test was a very invasive procedure, with plenty of risks of its own, and he was amazed that she'd recommended it on the basis of just one infection. He told me to ask her why she'd recommended it, so I did, and her answer was, "Well, he's a twin, and you'd be really incredibly lucky if there wasn't something wrong with him". Needless to say, he didn't undergo the test (and never had another urinary tract infection) and I switched pediatricians.
13
@Judith I am impressed that you were able to speak to your OB. Nowadays, where I live, health care relies on online portals. I have made requests to talk to a doc but, so far, no doc calls me back.
My longtime primary retired a year or so ago. She did not come to the phone but she actually phoned me if I wanted to speak to her. A few times, she phoned me on her own.
My new computer-harnessed primary does not, I am certain, ever pick up a phone to talk to a patient.
4
@Daffodil I'm 70, and my sons are 34, so this was a long time ago. My obstetrician was terrific. He'd been a respiratory therapist before he became a doc, and he told me himself that he thought that going to medical school later affected his entire approach. At any rate, he was one of the best doctors I've ever had, and I knew I could count on him.
2
@Judith Your OB/GYN doc knows nothing about the reommendations for UTI testing in young children.
AAP guidelines state that infant boys with confirmed UTI should be screened with a renal U/S and VCUG to r/o any comorbidities such as vesicoureteral reflux or posterior valves.
Your pediatrician didn't explain it well, but she was right and your OB was wrong.
Next time if you doubt your pediatician, go get a 2nd opinion from an expert on kids, not from an OB/GYN who knows nothing about kids once they leave the womb.
If a heart surgeon recommends surgery, are you going to get a 2nd opinion from a orthopedist?
12
No question this is true. My mother, with terrific health, lived to a good old age. But in the last 2 decades we had to advocate strongly on her behalf. Doctors were quick to think "she's old," but we had seen and noticed other factors. One internist said take her home and make her comfortable, it's cancer. She lived 20 years longer (it wasn't cancer). Another said she had Parkinson's (she didn't, it was a drug reaction). She developed diabetes at 90 -- which the ER, not her GP, found. And on and on -- yes, she was old, but thanks to us, she lived to be much older. She was the first to laugh about how many times they basically had her dead or dying.
65
@Andy Me to, My mom now 96 would be living in a nursing home if not for me refusing to follow doctors orders.
She a little fuzzy but still in independent living she (my diagnosis) had small stroke misdiagnosed at UNC Geriatrics as Alzheimer's . I hired a private therapist and did the rehab myself. She recovered. She is enjoying life because I largely keep her away from doctors and refused most medications, all of which were unnecessary.
I reached the point for myself that unless its a broken bone I'll never go to another doctor.
5
I am sure there are cases where an electronic medical record (EMR) can nudge a physician in the right direction. But, there are many more instances where EMRs lead to poor clinical decision making. EMRs are designed and marketed primarily to maximize revenue for hospitals and physicians. This necessitates that EMRs have a rigid input structure with endless nested click menus that requires physicians and nurses to spend hours each day inputting clinically irrelevant information into a machine. And so all this data inputting limits direct hands on interaction with patients and thus many subtle, but important, aspects of the history of the patient’s illness are missed. Attending to the machine in the room also distances the clinician from the patient emotionally which degrades trust and reduces empathy.
One should be very wary of trendy memes like “nudging”. I am quite concerned the “nudges” in the EMRs will quickly move away from limiting cognitive biases into covert means of directing care for economic reasons.
120
@Barrel Not to mention they increase the likelihood of physician's using mental shortcuts since they increase cognitive load! Physicians are already very busy- having 25% of their thought process being taken up by making sure they hit the right check boxes doesn't help
41
@Barrel
A medical system focused on maximizing profits (and profit per patient) will certainly view patients as consumables or profit extraction sources. A record-keeping system optimized for this profit will not serve patients well.
I am a Kaiser HMO patient and appreciate the value of accurate, portable medical records. There is no need to attempt to remember entire vaccination records, diseases, allergies, medications, surgeries, etc. This is both a huge time saver and also provides far more accurate information. It also saves many tests and treatments that become unnecessary with a trustworthy record.
Expert system based AI diagnosis has long proven to be more accurate than physician based diagnosis. However, an expert system used as a guide by an observant an knowledgeable physician works better than either by itself.
Certainly there is an entire industry designed to optimize revenues from Medicare and Medicaid based on coding of diagnoses and procedures and complications. There is effectively no penalty for over-coding a diagnosis or procedure. This is essentially maximizing legalized theft of our medical dollars.
However, there is little continuity in medical care providers today. Your doctor will be different over time, and from ailment to ailment. Without portable EMR, care is far worse.
4
Managed care, insurance -driven treatment options, for profit hospitals, electronic record keeping - all wrapped into one nightmarish package - is making the practice of medicine increasingly undesirable for the practitioner and the consumer. What has been a science and an art is suffering and creativity along with critical thinking are devalued and dismissed. Thinking outside the box, or shifting one's problem solving perspective (i,e, vital executive functions) can be augmented with algorithmic paradigms, but sound medical practice in the end involves a collaborative venture between medical personnel and the person seated before them - increasingly this is becoming a lost art.
49
This is not news to those of us in medicine. I learned about all of this in medical school, 30 years ago.
However now that it is making its way into the lay press I can hardly wait for administrators - who seem to know much more about medicine than I do - to incorporate these findings into new strategies to "manage" me and my colleagues.
I also eagerly await the IT department incorporate these findings into the electronic medical record, constraining my behavior in order to protect patients from my cognitive biases.
Seriously though, a profession with a long history of progress , self-correction, and self-regulation has lost control to the folks who control the purse-strings. If you think a system with docs and their cognitive biases is bad, try one with no docs at all.
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@Victor
You mean, just purse-strings? That's a premise for a science fiction story.
1
Ah! But let us not forget the heavy hand of “ malpractice lawsuit bias!” Very real and sadly responsible for almost mandatory “defensive medicine bias!” Defensive Medicine, alas, often overrides everything else by necessity!! A pity!
Also, in the name of computer driven extreme accuracy of everything as it refers to aforementioned left digit bias, how far back do you draw the line. Is a person 79 yrs and 10 months really 80 in your example? How about 79 years and 8 months? The line must be drawn somewhere and the logical spot is that the day before one’s 80th birthday the patient is 79 years old (if limited to talking just in years!)
I remind everyone, no two patients are exactly the same. What’s right for one may not be right for the other even if both are exactly 80. Knowing that in advance is the truly tough part of medical practice!
20
Very interesting piece. Weird though thay it doesn't even mention Jerome Groopman's pioneering work on this topic in his 2007 book *How Doctors Think*.
13
It will get better when the patient is examined by the plexiglass bulb of an AI doc, before it gets worse.
3
Thinking, Fast and Slow, by Daniel Kahneman.
15
This analysis focuses on a specific cognitive bias (left-digit bias) while missing the larger issue. Western medicine relies on categorical diagnosis: a patient either fits a diagnostic category, or doesn't. The cut-points are arrived at empirically, but are inherently arbitrary. Logically, it doesn't make much difference if the patient is 79 or 80. Likewise the exact figure for the fasting glucose or the resting blood pressure.
While it's important to avoid left-digit bias specifically, it's far more important to view diagnostic categories as helpful guidelines. They don't define the individual patient.
29
@Steven Reidbord MD
There is a larger issue still. Fasting glucose or resting blood pressure and the other markers can all vary wildly within a couple of hours. What good are empirically determined cut-points when blood glucose varies 15% in a day, and blood pressure can vary 30% over a day.
18
Bias is everywhere. You can see ten different doctors and get 10 different approaches to your health or problem. The optimism bias can cause delays in diagnosis and treatment. The worry bias has you getting way more medical evaluation and treatment than you need. The law of parsimony has you never considering rare illnesses and maladies. Things that occur infrequently are frequently missed. The best we can hope for is good communication and not rushing to judgement and always considering the worse case scenario. Perfection can be aimed for, but never reached. This is coming from a Family Physician with 38 years in the trenches.
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@Tom
Tom, bias may explain some of the differences of opinion, but as a fellow physician, I'm sure you would agree that a lot of it is that for many of the treatments docs offer have little science behind them.
I always laugh when I read people attack treatments of mental illnesses saying they don't have much science behind them when there's actually more research to support them for many of the common treatments used to treat physical problems.
Docs for years have prescribed opioids for chronic pain although there is virtually no research to support their use for this and tens of thousands of people have had back surgery for pain alone when there's nothing to show that this is more effective or even as effective as more conservative modalities.
The sad truth is that for all the knowledge we've gained about the human bodies and the diseases it's prone to, there is still much we don't know.
25
@Steve
I agree. Evidence based decision making should drive what we do as much as possible. But, I am also aware that placebo effect and the human need of just validating a patient's symptoms, worries and life stressors play a big part in what we give to our patients. All are hard to measure and provide evidence that they are effective. I have always liked the quote "Good doctors treat the disease. Great doctors treat the patient with the disease". And this also "It is as important to know the patient's biography as it is to know the patient's biology".
28
@Tom
I was so glad to undergo a comprehensive MRI of my major organs because the doctors wanted to make sure I did not have a dangerous blood clot . Now I can rest knowing that I don't have any cancer silently growing. This is coming from somebody who works with cancer patients. Most of the people I work with are paranoid because we see this daily where the cancer is diagnosed too late
8
Left digit bias is easily dealt with by presenting the information graphically.
13
@Jonathan Katz My thought as well- and in addition, not making decisions based on sharp (discrete) categorical divisions (such as age in 40's, 50's) that don't exist in reality. Most quantities are continuous and decisions need to reflect this.
6
The more stressful the environment for physicians, the more likely they are to make decisions based on bias, because they don't have time to think more deliberately. We all do it, because we couldn't think through every decision in our days. It's just that the physician decision has greater consequences. One strategy that patients and families can use is to draw the physician's attention to the characteristic or behavior that differentiates them from the bias you are concerned about. When my Dad was hospitalized at 93, we deliberately spoke to the staff about his recent goose hunting trip to Canada. They all remembered that and it make him like a very active senior, not a 93 year old man in room 4250. I've know of others using the same techniques, both for themselves and their families. In an article in JAMA, a physician wrote of her aunt who had a disability suffering a medical crisis, and the patient went out of her way to demonstrate her physical and cognitive function to the staff (walking around the unit, socially engaging with staff, mentioning her activities/interests) so that they would see her as a highly functional adult, rather than as a "disabled person who has lived a hard life."
51
@2much2do
Totally agree! I had to "sell" myself during a recent hospitalization
14
@2much2do I learned a valuable lesson many years ago when a new doctor walked into the examining room and found me reading a physics journal. He was stunned and cowed. I was instantly elevated from Anonymous Naked Guy to Actual Scientist. It helped that most doctors almost didn't get into medical school because they did so poorly in their physics for poets course. My wife is 72 and is seeing new doctors for serious medical problems. I don't want them to treat her like another little old lady. I make sure they know that she is a retired professor of psychology, psychiatry, neurology, neuropsychology, and several other ologies.
24
@Paul Kolodner I'm in public health as an epidemiologist. I've found that telling doctors this changes their approach to me a lot. I appreciate it though, because it means I learn a lot about their processes when I go to the doctor.
10
It would be good to have this sort of research on nurse practitioners. These people do a lot of the diagnostic work at clinics, and I frequently wonder if they truly have the depth of knowledge, experience, and self-awareness to accurately determine a patient’s problems.
18
@Gaston Bunny
I both work with Nurse Practitioners and am seeing one who is monitoring my case post-accident in my regular doctor's absence. I have been extremely impressed with her grasp of knowledge and the nuances of my case, as well as her availability. Oftentimes it can be difficult to reach ones regular physician because they are just so darn busy! I am very pleased with the personal level of care I am receiving. It was also easier to get disability forms signed.
Physician Assistants and Nurse Practitioners are here to stay. I think that we should be seeing more of them in isolated places where health care is practically non existent.
22
Cognitive biases exist because people are...people. It's how our brains are constructed and adapted over millenia to survive. Eliminating bias is impossible; the comments in the article about AI and electronic record system "nudges" simply substitute the biases of those writing or ordering the code for those of the physicians. Be careful what you wish for.
29
Biases can be seen as materializations of a trade-off between thoroughness and efficiency. We do not have the time or the resources to make certain sense of what is going on, so we rely on heuristics based on our experience and worldview to help us decide, especially in deep uncertainty.
15
@Alexandre Goncalves da Rocha
"Biases can be seen as materializations of a trade-off between thoroughness and efficiency."
Not quite ... what you describe are termed heuristics. Cognitive biases are something else. Unlike heuristics (which are learned), most cognitive biases are "hard wired" into our brains having been beneficially adaptive during the early development of our species.
3
And we are talking about physicians in two countries where medicine is indeed practiced, but, imagine how this "bias" factor affects someone's health in countries where you don't get treatment unless you bribe the doctor... there, I guess a woman going into labor without the money under the table can be sent away as suffering from temporary aerofagia.
2
@Justitia
More llikely, she will be given a quick c-section. Look at the c-section statistics for poor countries. Once they move births to hospitals, rates exceed 50%.
1
Fourth leading cause of death in the US - medical error.
20
@Eli Often stated, but not true (https://sciencebasedmedicine.org/are-medical-errors-really-the-third-most-common-cause-of-death-in-the-u-s-2019-edition/)
11
@Eli
This is false. Cite your source. This is a common myth perpetuated by Facebook professors.
7
@Eli This has been proven incorrect- unfortunately, the meme lives on. https://sciencebasedmedicine.org/are-medical-errors-really-the-third-most-common-cause-of-death-in-the-u-s/
2
One bias that I see often that needs to be addressed:
False accuracy bias. I see this all the time.
Fifty years ago when our meteorologists gave a forecast they would predict the possibility of rain or snow as "three in ten" as opposed to 30%. Expressing it in terms of percent implies that the accuracy of the data allows for more precision than is true. That is why you would never hear a modern forecast call for 31% chance of rain. The reality is that the forecast is really only accurate to 1/10 or perhaps 1/5.
If you polled only 10 people and 4 were for Bernie Sanders, it would be wrong to say 40% of the electorate were for Bernie Sanders.
Imagine if everyone expressed everything in terms of parts per million.
10
Regardless of the results of multiple studies and multivariate analysis there is still a role for the physician to practice the "Art of Medicine." As a doctor you can not help but to be swayed by your own personal experiences. Sometimes when you see a patient - something about the situation reminds you of a previous event that was unexpected. More often than not you are wise to consider and possibly heed this warning. There is still a role for clinical intuition. i.e. Bias is not always bad.
32
But you still need to know your own biases, so that you can account for them in decision making.
19
@William Feldman As in all areas where the current trend is to blame bias for the problem (hiring, police treatment, sentencing, selling of homes), the preponderance of evidence shows that the effect of bias is small compared to other matters. Whether a physician believes a patient is 79 or 80 has a negligible effect on decisions compared to the assessment of the disease and choice of therapeutic options. The only areas where bias has a significant effect is where it is applied overtly and intentionally, as in choosing who gets admitted to Harvard.
10
Since I don’t have access to the NEJM article to access the left digit bias for those younger or older than 80 years it is difficult to determine what other factors could be influencing decision making. Coronary artery bypass surgery in the elderly is with increased risk of morbidity and death. It appears the study design was extraction from Medicare records which limits the data available. Outcomes in those over 85 particularly with regard to death. This may not be bias but good medical decision making near end of life.
https://www.sciencedirect.com/science/article/pii/S0003497507026550
12
Let’s establish a few givens:
Doctors are smart.
Doctors are science-conversant.
OK?
Doctors are also part of a self-reinforcing professional group with its own strictures on conduct. This leads to severe bias. We have “best practices” and “fraternal” behaviors from this.
Doctors practice medicine now not that Hippocrates is looking over their shoulder but a band of lawyers.
Any algorithm or AI just is building bias by design into the process. All computing has bias.
A patient has become a commodity.
Here is a test for every doctor and every health care provider: Am i treating the patient before me as a means to an end or an end in herself?
I saw a doctor the other day with a group of letters trailing his name that I could readily identify: MBA. Not a symptom, the disease.
41
Cognitive biases are so ingrained in our daily instantaneous thought processes, that they are almost impossible to foresee and then program against. If you will notice, the study and article offer no ready solutions to the issue other than computer software "helping" Dr's make a better conclusion. Software that pushes Drs to make decisions is a whole other can of worms. Personally I look for Drs that are intelligent and good listeners and staring at me in the eye: not easy to find.
72
While this is a little esoteric and technical and only a small part of the overall problem, the basic fact is that doctors and other. medical people are just like any other profession.
You have the good, the bad and they ugly.
The only difference is that the. medical community deals with your life and health.
Treat them like any other profession. Educate yourself and try and find the good ones and eliminate the bad ones.
17
Imagine a medical system that was designed around health outcomes, and not to ensure enormous profits for the insurance/hospital industry.
I know, crazy right? We can’t be having *socialism* in America!
132
As healthcare professional, this is always a unanimous advise from legal experts: defensive practices! People scrutinized every word you wrote and every word you said, sometimes I felt we had to strive to be better than God!
8
@Vivian I would say the article is pointing to the opposite: how personal biases, not interest in avoiding lawsuits affects physician decisions.
6
This may lead to another problem: the "liability bias". Instead of patient safety and health management, doctors and hospitals focus on legal risk exposure, something that may hamper or skew the practitioner's sensemaking.
10
When a medical student or resident presents a new patient to me, I always push back on the typical use of identifying data, e.g. “this is a 23 year old African American woman.” My response is typically, “Why is the fact that she is African American the second most important thing I need to know about her?” To be fair, excluding even specific genetic risks that might be higher in that population than in non-African Americans, there are actually many reasons why that information might be relevant regardless of the medical sub speciality, such as less access to care, or exposure to other risk factors. But that is not the reason the information has been provided. It’s just how medical professionals have been trained. My intention in challenging this ritualized description is precisely what this article addresses: raising awareness of how prejudicial decisions can be made regarding a patient and her care based on rote, reflexively included information that impedes a more accurate formulation.
Your article makes two things clear-that any of this seemingly straightforward information (age, gender, and what is referred to as race) among many aspects of a patient’s presentation can distort a physician’s critical thinking, and the sooner physicians recognize that, the better.
53
You have to pick something to identify a person with, and age and race seem as good as anything else. At least they have some medical significance. Otherwise, we could say "This is an unmarried Democrat" or some other combination of non-medical traits.
22
@Colin Barnett I really like that "unmarried Democrat"! As a retired ER nurse, I remember that we would announce new arrivals informally to the grumpy doc waking up with more graphic descriptors than anything that ever appeared on a chart, including references to political affiliations and unusual affects or physical attributes. The purpose of this behavior was not to belittle or "other" the patient, but to direct the care of the individual in ways that would take in to account factors that, if not acknowledged, might lead to misunderstandings or missed diagnoses. You are correct that ritualized recitation of fomulas like "single black female" are destructive to critical thinkiing. Someone somewhere commented that many modern doctors go through med school memorizing cookbooks from professors who basically did the same.
13
You grossly exaggerate the effect size of cognitive biases. They have small effects. Occasionally they can play a part a major misdiagnosis, but only as part of a larger picture of multiple small errors leading to one big misdiagnosis.
The electronic health record, far from being a cure, actually creates distractions and contributes on its own to error far more than cognitive biases.
27
JB, catastrophic medical mistakes are just like plane crashes, a series of small mistakes that end up in a disaster. Your dismissing “small” mistakes is completely incorrect.
2
Gender bias is worse. If you have a 79 yo woman present with an MI versus a 79 yo man and make all other variables equal, the man will get much more aggressive care. For the woman you will see "medical management." After 23 years as an MD I have seen it too many times to count.
131
@The East Wind that's ok, the medical management may be more appropriate for both of them!
6
@The East Wind. Unfortunately, the wrong preconception that men die mainly from cardiovascular diseases and women from breast cancer is indeed widespread, and affects (maybe better: infects) also the medical community. That bias also works in reverse: men who do develop breast cancer (rarer than in women, but it does happen) are frequently not diagnosed until the cancer has metastasized.
7
@Pete in Downtown
True- but the leading cause of death in women is heart attack- MI, breast cancer is not the leading cause of death in either. When women DO have MIs their outcomes are worse and mortlity is higher- but the bias remains.
11
My guess is that most doctors don't spend enough time with their patients to discern what the real problems are. I've been fortunate not to require the services of the medical profession up until the last 5 years and that last 5 years has been a real eye opener for me. I've had ONE physician in that 5 years who has looked me in the eye, sat patiently and asked relevant questions, and really listened to my answers. One MD spent 2 minutes with me with his back turned the entire time. And I'm not the only one who has experienced this treatment; most of my friends report the same thing. Talk about all the software you want, but REAL contact with the living humans you're treating will go a long way to reducing bias and error.
180
@Lucy S.
Bravo, Lucy. The meat of the issue here, as, after a move, my last few years of experience with new doctors has proven. I miss the eye contact, the listening, and the comfort of my old doctor's experience and humanity!
26
@Lucy S.
Precisely why we need a national health program instead of one dictated by the profit motive of insurers and pharmaceutical companies.
12
@Lucy S. Many doctors agree and are leaving the field of medicine because they are fed up with the current system which does not value a patient-doctor human interaction. (a) Our govt set rules to encourage/mandate adoption of electronic medical records systems (b) said EMRs are built to facilitate billing and require tedious documentation that consumes valuable time that should be spent with patients (c) the increased time needed to satisfy the documentation requirements of the EMR ends up degrading the experience in clinic for both patients and doctors. I am a physician and the only way I can talk to patients face to face without documenting on a computer during our visit is if I save all my charting for the end of the day and take it home with me (which is what I have been doing all day Saturday at home - catching up on notes for patients I saw this past Thursday and Friday). Not asking anyone to feel sorry for me (this is my job), but I want to explain that there are systemic pressures that force doctors to practice medicine in front of a computer screen - and most of us hate it.
7
About 15 years ago when I was 39 YO I was having cataract surgery at the Cleveland Clinic and about to be wheeled into the procedure room when the nurse looked at me and said in a panic “Oh no! Do you still get your period?!” When I said “yes” she had to run to another building to get and administer a pregnancy test on me which was required before all surgical procedures.
Apparently the cataract surgery intake form designed by the doctors didn’t include the pregnancy question because the form authors assumed all cataract patients are elderly.
In this case the bias was literally institutionalized. It took a nurse to identify the flaw in the system and fix it.
144
@JAS
That's ridiculous! I had my period into my fifties and am sure I'm not alone
11
@FerCry'nTears Once I read my records and found that I was post-menopausal, only I wasn't.
15
@JAS
the bigger issue here is the wackiness of needing pregnancy test to get your cataracts done. this is 100% defensive medicine.
15
Why not make the use of software/AI to assist with the diagnosis to mitigate such biases?
2
The article discusses this possibility in the last several paragraphs.
3
Because we are human, bias is part of everyday life. I believe that increased use of computer programs that are developed to provide medical 'advice' based on absolute data points without bias will truly 'nudge' medical providers towards more unbiased medical decisions.
I believe that bias on the part of physicians increases with length of practice, which is one reason I choose physicians with training from the most respected institutions who are no more than 40 years old, when possible. And I receive my medical care at a major University Medical Center.
I have several serious medical conditions but I look very healthy and at least 15-20 years younger than my actual age. Therefore my outstanding Immunologist reminds her accompanying cohort of Fellows, Residents and Medical Student to "Look at her CHART, not at her" to help them avoid underestimating the level of care that I need.
23
Yes, I discovered it's a bit of a curse to look much younger. People expect more of you.
6
@Elaine Dittmer
I would say, "Look at her chart AND look at her." Both are important.
I think that there are a lot more doctors who look at the chart too much than doctors who look at the patient too much.
22
@AH Or less, in other contexts. When I was (relatively) younger, but looked much younger, it was hard to get people who didn't know me to take me seriously until I pulled rank, something I'd much rather not do.
8
The biases in medicine are not limited to cognitive, and certainly not to physicians, but are also ingrained into the digitalized, electronic medical record, system that now controls much of our health care system.
Case in point: I had a surgical procedure the day before my 64th birthday. The computer generated identification band applied to my wrist when I checked in for the procedure listed the date, my birthday and my age... as 63 years old.
5
Which was correct.
9
@Anthony The band was right. What's the problem?
7
There's limits to everything. What did you expect?
3
This is interesting. I always try to stress to Med students and residents awareness of their cognitive biases in medical decision making. The left digit bias is something I’m sure I’m guilty of despite always having a suspicion of its existence.
As physicians we should strive to improve our abilities every way possible.
However “fixing” this issue of biases is not going to solve the serious problems in our health care field any more than cutting reimbursement rates for physicians will control costs. In reality it’s not even a top 10 issue.
In fact, of all the players in the medical industrial complex, it is the physicians who have sacrificed the most in the effort to improve it.
78
The only reason the obstetrician was more likely to switch delivery modes for the next patient (C-section vs. vaginal delivery), regardless of the appropriateness for that next patient following an untoward event is concerns over becoming a party to a lawsuit. In NY, alpractice lawsuits from birthing can be filed up to the age of 18!
31
@Shoofly
Well, no, in that situation there are 2 reasons why the obstetrician switches delivery modes regardless of what's appropriate: (1) fear of being plagued by malpractice lawsuits. (2) cognitive bias.
Seems like you're sliding into thinking that because physicians are vulnerable to lawsuits, some of them frivolous, we should be so overwhelmed with sympathy for them that we refrain from calling them out for cognitive biases.
13