I’ve Been Framed!
According to Graber et al4, diagnostic errors fall into three categories:
“No-Fault” Errors: The illness is silent, masked, or unusual in its presentation, or the patient misrepresents symptoms.
System-Related: This includes erroneous information in the patient record, technical and/or equipment failures, incorrect test results, poor coordination, and organizational flaws.
Cognitive: Herein lies faulty data collection, interpretation/reasoning, or incomplete knowledge on the part of the clinician. The information necessary to draw the right conclusion is available, or easily found, but the wrong conclusion is reached.4
What really intrigued me is the cognitive framing effect. This is when the diagnosis is unduly influenced by collateral information. There is considerable evidence that we make irrational or biased decisions based on how the expected outcome is framed.
Shortly after taking the malpractice course, I was working in an allergy and asthma practice and had an immunotherapy patient on my schedule who was listed as “same day/sick.” I entered the room thinking her symptoms could be related to her allergic rhinitis or extrinsic asthma or perhaps an adverse reaction to that week’s allergy shot. What I found was a 38-year-old woman with a three-day history of a 103°F fever, severe neck pain, headache, and severe malaise. Sparing all other information, suffice it to say she was sent directly to the emergency department (ED), where she was admitted.
I am also aware of a case in which a patient with shortness of breath was treated in an ED with an erroneous diagnosis of COPD with a “long-standing benign murmur.” She was in a room with nebulizers on the nightstand and a diagnosis of “COPD exacerbation” and later died of aortic stenosis. Sometimes, inaccurate prior information or collateral evidence frames a problem as pulmonary when it is really cardiac.
Essentially, clinicians may be influenced by the way in which the problem is framed. For example, perceptions of risk to the patient may be influenced by the possible outcome (eg, is the patient likely to die?), the type of clinic, or even the time of day.5 Framing may also occur when another clinician presents a case to you that is influenced by his or her own bias.
On the next page: How to avoid framing bias >>
