Patient Influence and Visceral Bias
Our patients are individuals with a variety of personalities, needs, circumstances and situations that may influence our interactions with them and therefore can impact the clinical decisions we make.
The influence of affective sources of error on decision making has been widely underestimated. Visceral arousal may put us at risk for making poor decisions. Countertransference, involving both negative and positive feelings towards patients, may result in diagnoses being missed.
Additionally, patient behavior can negatively impact our diagnostic decisions. A study asked 63 family practice residents to evaluate six vignettes in which patients were depicted as difficult or neutral. Three clinical cases were diagnostically simple and three were complex. The participants were asked to diagnose the patients first quickly and then through deliberate reflection. Participants also rated the patients’ likability. The study showed that disruptive patient behaviors caused the participants to make diagnostic errors more often and that likability ratings were lower for more difficult patients. Importantly, deliberate reflection improved initial diagnostic accuracy, regardless of case complexity and patient behaviors.1
A Case of Visceral Bias
A 14-year-old female asthmatic patient had a long-standing relationship with a pediatric practice. The mother was well known to the practice as a “worried-well” mom. Recently, the pediatrician had referred the patient to a psychiatrist because the mother suspected that her daughter had ADHD; however, the psychiatrist said the child did not meet criteria for the diagnosis.
At this visit, the patient was brought in for asthma exacerbation. Before he had a chance to examine the patient, the mother asked the pediatrician to start her daughter on steroids. The pediatrician quickly found himself feeling irritated by the mother’s request. After the pediatrician determined that the child’s inhaler was missing, he renewed the medication and told the mother that her daughter did not need steroids. On the way to the pharmacy to pick up the inhaler, the child began to have trouble breathing. The mother called 911 from the roadside. The patient was taken to the hospital, where she was intubated for status asthmaticus.