What's your Bias?

[AJ Lievre]

Interesting read. We all have our biases. Any particular bias speak to you? Reflect back on a patient encounter where your bias led to an error in diagnosis or judgement. Should that patient have been referred sooner or just treated differently?

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[August Winter]

Unfortunately I think several of these biases are relevant to my care. One that I have started to recognize more in my practice is Premature Closure. With trying to rule out diagnoses early on in an evaluation I feel like this is less of a problem at the initial patient assessment. Where I start to run into issues is a hesitancy or blindness to reassessing during a PoC if what I am doing does not seem to be working as well as I would like. I have noticed I am much less eager to jump in and re-evaluate things than I should be because I already have a diagnosis that “makes sense”. Not as frequently, but I have found myself guilty of the Psyche Out bias. For patients with chronic and high levels of pain that also have significant psychosocial factors it sometimes is too easy to significantly ignore the actual musculoskeletal root cause of their symptoms.

Besides the above examples, I think where I have run into trouble in treating patients ineffectively due to bias has been when I have taken over responsibility for another clinician’s patient. Especially as a young clinician I look at nearly everyone as more of an authority than myself. I can think of one situation as a student where I was treating a young woman for shoulder pain, and discounted treating at her cervical spine for a significant amount of time because the initial PT doubted any cervical component. In hindsight I should have independently reassessed and potentially started on treating her neck more quickly.

[Michael McMurray]

As with August, I feel that several of these biases may apply to me in my first year as a clinician. The category that stuck out to me the most was cognitive bias related to heuristic failure. I think the ones I have allowed myself to fall into include anchoring and premature closing. Retrospectively looking back, I think often times I see an intake form and/or hear a subjective history and think that it has to be a certain diagnosis. In times that the objective examination begins not to fit my primary diagnosis I become flustered in trying to re-direct my exam. Not coming up with the appropriate diagnoses has left my exam incomplete or fractured. I think that premature closer is another one that sometime clouds my judgement, I can think of one or two patients that I have thought they fit a certain diagnosis. When they are not responding to treatment as expected, I wish I would have gone back to re-examine different potential diagnoses.

What I took from this article and would like to implement in my practice is the solutions they provide in avoiding diagnostic errors; particularly acknowledging that the initial “working” diagnosis may not be the final diagnosis, accept what you do not know, and being open to both confirmatory and nonconfirmatory data. Trying to hedge diagnoses and treating with several different treatments may not be as effective as applying a primary diagnosis and not hesitating in re-examining and re-evaluating them if necessary.

[Erik Lineberry]

As others have stated I feel like I tend to rely on anchoring and premature closure. I find myself latching on to a common diagnosis or the first thing that the pnt’s subj history leads me to consider and losing perspective of other features of the case. Due to this I see myself falling into a frequency or availability bias. This article was a good read to allow for reflection on how I evaluate and treat patients. From what I gathered a big key to an effective eval is to not rely heavily on other provider’s data and to allow time for reflection of a presented case to avoid heuristic bias.

[Kristin Kelley]

So has anyone encountered the “difficult patient?” The one who will do NOTHING, has a negative attitude, has no motivation, and is an energy sucker?
Countertransference outcome bias anyone?

2 Weeks ago I evaluated her. This pt is a self proclaimed agoraphobic 70 y.o incredibly deconditioned pt with chronic pain and a laminectomy gone bad. She literally yelled at me during the eval telling me I could not help her, I would only cause her pain and the only reason she attended the eval was because her surgeon told her it was PT or another surgery. Fun times. I took the time over the next 4 visits to provide her reassurance, a positive environment but still pushed her a little out of her comfort zone to slowly advance her mobility and strengthening and finally broke through w/her today as she told me all about how proud she is of her kids and the grandson she has raised from birth who has significant special needs. This “difficult patient” softened today and turned into someone who is actually progressing (slowly) in her functional progress and may meet a goal or two in pain control and using better functional strategies to care for herself.
Please remember to provide health CARE to those who may seem unreachable. You may be the first person to actually have taken the time to break through the tough exterior to the hurting person (physically and/or emotionally)

[August Winter]

Good point Kristin. I’d say the only negative of this article was that there were too many biases too choose from (sadly), but realistically the one you mentioned should be high on my list as well.

I had one patient with lumbar stenosis early on during the residency whose outlook on their symptoms and overall personality wore on me. I realized that my dislike for his negative attitude affected my care. He ended up coming back to therapy several months later, and I think I surprised him by being more upbeat, open to his concerns, and genuinely excited to try a bunch of different interventions for his home program. His response was considerably different, and I wonder how much time I wasted by letting his personality impact my decision making earlier on.

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