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May 2015

My Most Informative Error

Author Affiliations
  • 1Ethox Centre, University of Oxford, Oxford, England
  • 2Hebrew University Hadassah Medical School, Jerusalem, Israel
JAMA Intern Med. 2015;175(5):681. doi:10.1001/jamainternmed.2015.105

I was going through my usual weekly early-afternoon clinic when I suddenly noticed that my manner with the patients was anything but usual.

I always love to chat with my patients. I long ago discovered that being curious and sincerely interested in a patient’s life and circumstances may take a little time but invariably adds a lot for both parties. The patient feels acknowledged by the personal attention, and I also am soon rewarded by bonding, empathy, and commitment, not to mention the occasional astounding story. With time, this approach became second nature. I felt that it transformed patients’ satisfaction, trust, and adherence, and it invariably made my practice less tiring and more interesting.

Today, however, I was not only curt and practical but found myself dismissing each patient in record time, armed with little pieces of paper commanding prescriptions, blood tests, or imaging. To be honest, none were absolutely necessary. All served just one major purpose: going through today’s list of patients as quickly as possible.

That evening, I was due to give a lecture to a big prestigious audience. I was determined to arrive there spick-and-span, relaxed, and rehearsed. A good review of each patient’s medical history, examination, and medical record would have made many of the tests and prescriptions entirely redundant. However, my time was short, and the authority provided me by the white coat and my title made each of my actions seem credible to my patients even when they were just an almost transparent means of getting on. It was working well for me, but I was already feeling uneasy. Was I betraying my patients’ trust, exchanging quality for an empty ruse?

The lecture went as well as I could hope. However, the ease of carrying out this “deception” left me distinctly uncomfortable long after. Had it happened to me before? Do my colleagues engage in such faulty solutions as well? How often does it occur? What proportion of overuse of health services could be similarly motivated?

I soon realized that this might be just the tip of the iceberg: Are we not modifying our actions often not only to comply with our next commitment, but in implicit, perhaps subconscious response to patients’ looks, affluence, behavior, sex, age, or ethnicity? What portion of our daily actions, are in fact tinged by inappropriate considerations? How many other external factors are out there, skewing our judgment and decisions to suit our convenience or remuneration at the expense of the patients’ best interests?

When faced with a difficulty, I reflexively turn to the literature. One article in particular immediately rang a bell. I was a young resident when I encountered Eisenberg’s1 “Sociologic influences on decision-making.” It was a powerful reminder that no physician is an island and that deviated decisions in response to external factors have long been recognized. Then I found articles on disparities in the care given to vulnerable populations that were not related to clinical factors. Minorities, women, and the elderly population in particular were often undergoing fewer diagnostic procedures and receiving less comprehensive treatment. I decided to initiate a new study that identified no less than 75 different nonclinical factors that we may be susceptible to, highlighting their ubiquitous presence. Anonymous qualitative interviews with hospital- and community-based clinicians revealed their substantial potential to redirect decisions. One prominent factor was the misconception that the patient is seeking a referral, a test, or a prescription and will not be satisfied unless these are provided. In fact, research supported quite the opposite: patients most wanted their physician to listen to their concerns, examine them, and talk to them.

My experience that afternoon before my lecture made me very much aware of this problem. And being aware, I was now trying harder to resist those many pitfalls that may unknowingly affect my objectivity and undermine the quality of care I provide. It even became a regular part of my teaching to the final-year students, invariably leading to lively debates. Being human and susceptible, we probably cannot avoid these pitfalls entirely. However, increasing our mindfulness, reflecting on what we do and why we do it, and candidly sharing our troubles over coffee with colleagues who face similar dilemmas may improve our objectivity and render us more immune to those prevalent untoward influences that threaten to skew our actions.

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Article Information

Corresponding Author: Ami Schattner, MD, Hebrew University and Hadassah Medical School, Bilu Junction, Rehovot, Central 76100, Jerusalem, Israel (amischatt@gmail.com).

Published Online: March 9, 2015. doi:10.1001/jamainternmed.2015.105.

Conflict of Interest Disclosures: None reported.

Eisenberg  JM.  Sociologic influences on decision-making by clinicians.  Ann Intern Med. 1979;90(6):957-964.PubMedGoogle ScholarCrossref