Thursday, February 01, 2007

Influenced by....

If you recall, our dear ClinkShrink was recently ill with pneumonia and found herself the patient of a handsome young doc-in-the-box. She told us tales of her patienthood, and hid her doctor identity while the handsome young thing explained how the white blood count rises during an infection. Roy chimed in to say he also down-plays the doc thing when he's a patient: "I always heard that docs got worse care, not better. They don't get those nice explanations like you got, and the treating-doc tends to let the patient-doc drive the treatment plan bus more than is appropriate." I, on the other hand, can't stand relinquishing control, and could never lie low.

So, yesterday, I'm e-conversing with my wonderful friend, Linda, who is very sharp and very in tune to boundary issues. We got on the topic of something medical, and Linda e-mailed, "Countertransference, as you know, is a major issue in physicians treating physicians." She then steered me toward this sweet article by Jerome Groopman in the New Yorker, Medical Dispatches: What's The Trouble?

The article starts with a scenario starring Dr. Pat Croskerry, an ER doc who missed a diagnosis of cardiac disease in a slim, athletic, patient with no risk factors and a negative initial work-up. Dr. Croskerry assured the patient his chest pain wasn't cardiac, and oops, the patient bounced back later that day in the midst of an acute MI. Dr. Croskerry went on to study the cognitive factors which influence clinical decision making.

"But research shows that most physicians already have in mind two or three possible diagnoses within minutes of meeting a patient, and that they tend to develop their hunches from very incomplete information," Groopman writes. "The mistake that Croskerry made is called a “representativeness” error. Doctors make such errors when their thinking is overly influenced by what is typically true; they fail to consider possibilities that contradict their mental templates of a disease, and thus attribute symptoms to the wrong cause. "

Another type of error is deemed an 'availability' error: "Doctors can also make mistakes when their judgments about a patient are unconsciously influenced by the symptoms and illnesses of patients they have just seen." Ah, ClinkShrink didn't really have pneumonia, her doc-in-a-box missed the diagnosis of Multiple Personality Disorder because one of those clinky alters was coughing and the four prior patients had all had pneumonia! (Just kidding, there's only one ClinkShrink.)

Finally, Dr. Groopman goes on to talk about how doctors' feelings can get in the way of making the right diagnosis. He cites an example from his own practice, one where he missed finding an abscess in his favorite patient on the ward, a man he enjoyed discussing literature and running with.

"I was furious with myself. Because I liked Brad, I hadn’t wanted to add to his discomfort and had cut the examination short. Perhaps I hoped unconsciously that the cause of his fever was trivial and that I would not find evidence of an infection on his body. This tendency to make decisions based on what we wish were true is what Croskerry calls an “affective error.” Groopman goes on to write, "When people are confronted with uncertainty—the situation of every doctor attempting to diagnose a patient—they are susceptible to unconscious emotions and personal biases, and are more likely to make cognitive errors."

I suppose I wanted there to be a story about a doctor missing the diagnosis on another doctor, it is, afterall, what I was thinking about. This will be good enough, though. Our relationships with our patients-- perhaps even more so in psychiatry-- are complicated. Our feelings, our hopes, our own issues-- maybe they get in the way, certainly they add to the mix.

Post Script: Check out The Last Psychiatrist, post of 1/31/07: When the Patient's Parent is a Psychiatrist and a Patient and You Just Want to Go To Bed.