This is the 119th #WILTW
“Hospital Doctors miss signs of illness because of chronic staff shortages”
This headline played across news outlets and social media this week. Based on the results from a doctors survey it encapsulated the pressure currently felt by many health care professionals. Politics aside there remains increasing demand for services with a relative fixed amount of staff to deal with it. Additional challenges were revealed by the extent of General Medical Council training concerns at over 70 hospitals in the United Kingdom.
Regardless of the underlying reasons; patients expect not to have signs of illness missed which in retrospect should have been detected. This is not saying all diagnoses should be be correct or timely. Some conditions are difficult to detect in their early stages and some require extensive work up to define the extent of illness. However even with an increasingly litigious society a large amount of NHS funding is expending settling complaints which could have been avoided had appropriate initial interventions occurred. Why does this happen? Why do healthcare professionals miss seemingly obvious signs and symptoms? Obviously the reasons are multi-factorial. External pressures as noted in the doctor’s survey will play a part. However there are some intrinsic factors in the way that doctors make decisions that often cause problems.
Some of these Diagnostic Reasoning errors were reviewed in a blog published this week summarising a lecture delivered by Jonathan Sherbino. Jonathan works in an Emergency Medicine Department in Canada and has a research interest in decision making processes. System 1 (fast) versus System 2 (slow) thinking was reviewed along with some myth busting of how diagnostic errors occur.
One of these was speed of diagnosis. Evidence suggests that going slower makes you slow, not better. This isn’t saying going faster makes your more accurate but that you often gain little in the way of accuracy by spending more time thinking about a problem. Even more interesting was the fact in some studies interruptions, which would seem an inherently bad thing when you are busy cogitating a problem, didn’t seem to make diagnostic accuracy any worse. The final take home message was that reflection, in this case a cognitive forcing strategy of structuring a second review of your decision, only really benefited those with prior experience. Experience coming up again and again as the best way of avoiding diagnostic error.
This then asks some difficult questions of how we should best structure our healthcare service. Having more senior staff is something many Royal Colleges have been calling for for some time. But those senior staff need to gain their experience from somewhere which resonates with the blog’s author Jesse Leontowicz closing point to ensure that learners get experience in the Emergency Department and not just hope it happens. I’d add something else as well. Health care professionals, especially doctors, need to understand why they make mistakes rather than hope they don’t happen and be chastised when they do.
Learning the processes that facilitate making mistakes makes it much easier to avoid getting caught up in them.
What have you learnt this week? #WILTW
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This blog co-incides with the release of the summary of my induction lecture to our Emergency Department new starters (click here if video doesn’t play).
A previous WILTW has also covered cognitive error: