Diagnostic errors often result from inflexibility in thinking or "anchoring bias" in which someone has trouble letting go of an original thought or intuition. Basically, We often rely too heavily on initial information we receive. I recall a particular patient in my career in which I believe anchoring bias played a role in misdiagnosis. I remember this patient particular well because one she died, two she had a more rare diagnosis, and three I took care of her for a long time but could not cure her. This young (early 30's), married mother of several children whom happened to be a smoker experienced dyspnea for many years. She had seen at least 5 clinicians over the years many of which contributed her dyspnea to anxiety which was certainly on my differential initially as well. That is until I performed a pulmonary function test which I believe was in the range of 20-25% of predicted. I am pretty sure I asked the test to be repeated assuming poor technique but the results held true. At this point of course I did a more thorough exam which revealed a barrel chest and effort similar to a 70 year old with emphysema. As you may have guessed I ordered a test I had ordered multiple times before but always found to be negative thankfully. Although it was not negative in her case and she had alpha 1 antitrypsin deficiency. Anchoring bias must have played some role in this case and lead to diagnostic error which I am sure I had succumbed to myself many a time. Her dyspnea had become progressively worse through several years yet the impression never changed. Fortunately, once diagnosed we were able to start treatment which may have prolonged her life by several years but whom knows how much longer she would have had if diagnosed the many years previous when she first presented.
I can't help but wonder or even assume that anchoring bias play out in our inability to truly innovate in healthcare. Evidence shows that it is harder to innovate disruptively within an industry versus outside of it. In healthcare we constantly make small incremental changes but rare monumental changes that affect the larger healthcare system. I have certainly seen some evidence myself in the way of anchoring bias impacting decision making outside of the diagnostic process. Think of the reluctance to change even small things such as staffing models and sites of care like retail clinics and the rather slow movement of paying for and implementing telemedicine which one could argue is not all the disruptive.
So, what can we do both individually and as an industry? One thing we can do is reflect on our past decision making and about whether we rushed to judgement. Consider what resources of information you relied on to make the decision and had that information been gathered systematically. Did you take time to make the decision or come to a decision quickly upon receiving certain clues. Relating back to my patient I certainly rushed to think this patient was anxious based on several indicators such as what she was told in the past and how she relayed her symptoms. I was just fortunate enough to have spent more time listening and digging for additional information. As individuals we can be open-minded, seeking opinions, additional information, and alternate ideas, Try spending more time listening prior to sharing your own views right away to widen your knowledge and frame of reference. We also need to work toward avoiding another bias in confirmation bias which lead us to ignore evidence that contradicts our preconceived notions. As an industry we need to work with those outside of our industry and trial models of care outside of our traditional systems of care. The only way IBM was able to survive the PC was to set up a completely different unit of business away from their mainframe business because those in it couldn’t think differently.