Editorial |
The importance of thinking in occupational medicine
As a recently graduated medical practitioner developing an interest in occupational medicine, I worked in a practice in an industrial area servicing a number of small to medium manufacturing industries. Rather than sending injured workers to their own general practitioner, because of our location and focus on industrial injury, companies would send workers to us for assessment and management of their work-related injuries. On an average day, we could see between 30 and 50 mainly musculoskeletal complaints.While working in this practice, a young sheet metal worker presented to me with low back pain which had occurred while he was lifting and twisting in the course of his heavy manual duties at work. I diagnosed a musculoskeletal strain and as was standard practice then prescribed rest, analgesia and anti-inflammatories. Within a few days, his condition had improved somewhat and I referred him to the physiotherapist for some local treatment and exercise. Unfortunately, his improvement plateaued. I doggedly persisted in my approach but because of lack of improvement referred him for a computerized tomography scan of his lumbar spine. This showed some subtle changes in his L5/S1 disc and so I revised the diagnosis to that of a disc injury. Several more weeks passed and the pain still did not improve. The employer was (rightly) becoming frustrated and the patient was referred for an independent assessment. The rheumatologist he saw took the history and examined and investigated him. It was at this stage that his ankylosing spondylitis was diagnosed.
There are a number of causes of diagnostic error, including inadequate knowledge, faulty or inadequate data gathering and cognitive processing. While each of these areas is important, available evidence supports the latter as possibly being the most significant contributor to diagnostic error in a majority of cases [1]. In the example given above, at least part of the diagnostic error was as a result of a phenomenon known as ‘framing’. In this scenario, the young sheet metal worker presented to me from an industrial setting with a good history for a strain problem. Therefore, I failed to consider the (less likely) possibility of an inflammatory problem. I then ignored a possible clue (some improvement with anti-inflammatories) to the correct diagnosis and because I had made my mind up too early in the process (premature closure), I failed to make the correct diagnosis. It was left to another to review the individual and get it right in the end.
There is evidence in occupational medicine that a significant proportion of individuals presenting with what could be considered occupationally related conditions may indeed have an alternative explanation for the diagnosis [2].
Heuristics are short cuts in reasoning that are used to rapidly make decisions. They are often used by clinicians in daily practice and are often accurate and efficient but not invariably so. Croskerry [3] describes >30 potential failures in perception, failed heuristics and biases which he refers to as ‘cognitive dispositions to respond’ that may lead to diagnostic error. Some examples of these are given in Table 1.
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Occupational physicians should be aware of these potential causes of diagnostic error. Techniques can be learned which may minimize some of these common mistakes. One of these approaches involves metacognition. Metacognition is the ability to ‘think about how we think’. A metacognitive approach to problem solving involves stepping back from the immediate problem to examine and reflect on your own thought processes. By learning about the potential for cognitive error and learning skills in metacognition, the potential for making diagnostic errors may be reduced. Cognitive forcing strategies are approaches that may assist with this process. Some examples of these are given in Table 2 [4]. Other strategies include decreasing one’s reliance on memory, minimizing time pressures and receiving timely and adequate feedback on mistakes.
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In addition to thinking processes influencing diagnostic decision making, Croskerry has proposed that there is evidence from the field of psychology that how doctors ‘feel’ may also influence this process. In the area of occupational medicine, especially when dealing with matters of workers compensation where emotion often runs high, the role of affect may be particularly relevant. Strong positive or negative emotions have the potential to lead to bias in the diagnostic process, especially when the decision making is more intuitive than reflective. The issue of counter transference, where the doctor may feel positive or negative towards the patient because of previous experience, is an important issue when working in the workers’ compensation environment. So too is fundamental attribution error, where a patient’s behaviour may be judged in a negative way, influencing the standard of care offered (e.g. blaming the patient for claiming compensation and allowing this to influence the management of the injury) [5]. An adversarial medico-legal environment may also contribute to this problem.
In the situation described above, I should have asked myself ‘what else could this be?’ (a corrective strategy for ‘vertical line failure’). I should also have tried to consider the problem if the man had presented in another context, i.e. outside the work environment. When the young man's back pain was not improving as expected, I should have reconsidered the diagnosis and been prepared to re-evaluate. Of course, hindsight is a wonderful thing, and I have learned from my error and would never do such a thing again! Unfortunately, learning from past events is inevitably an imperfect process [6]. Hopefully, the humility that comes with reflecting on my mistakes will ultimately benefit my patients. My next error is likely to be somewhat different, and perhaps by working hard on cognitive de-biasing in my own thinking, I may reduce the error rate somewhat. I would encourage my colleagues to do the same.
1 Department of Rheumatology, Southern Adelaide Health Service. Flinders University, Adelaide, South Australia 5042, Australia
2 Research to Practice Group, Division of Medicine, Cardiac and Critical Care, Southern Adelaide Health Service. Flinders University, Adelaide, South Australia 5042, Australia
e-mail: michael.shanahan{at}health.sa.gov.au
References
- Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Ach Intern Med (2005) 165:1493–1499.
[Abstract/Free Full Text] - Atcheson SG, Ward JR, Lowe W. Concurrent medical disease in work-related carpal tunnel syndrome. Arch Intern Med (1998) 158:1506–1512.
[Abstract/Free Full Text] - Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med (2003) 78:775–780.[Web of Science][Medline]
- Redelmeier D. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med (2005) 142:115–120.
[Abstract/Free Full Text] - Croskerry P, Abbass A, Wu AW. How doctors feel: affective issues in patients’ safety. Lancet (2008) 372:1205–1206.[CrossRef][Web of Science][Medline]
- Croskerry P. Context is everything or how could I have been that stupid? Healthc Q (2009) 12:e171–e177. (Spec. Iss.)[Medline]
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