Straight Talk About High-Risk Patients from a Medical Heuristic Lens

    Reflecting back as an orthopedic hospital-based and former Emergency Medicine Physician Assistant (EMPA) at an urban inner city Level I trauma center, one of my biggest challenges was not only to spot the drug-seeking patients or rule out subtle life-threatening presentations but also to juggle and manage flawlessly two other high-risk types of patients: the “bounced-back” and the unimproved “signed-out” ones. Two potential medical malpractice time bombs waiting to happen most likely if not afforded the right clinical follow-through diligence or taken seriously on your watch, particularly when the liability factor was transferred to you by a recently graduated colleague or an intern completing their shift. 

    Why is that you ask? Well, possibly because these two types of patients in some instances are usually either insufficiently or possibly improperly worked up as I came to find out many times to my dissatisfaction. Thus, easily leading you astray (if not cautious enough) in these supposedly ready-to-go  “signed off” patient-shared presentations by the initial clinician.  Especially when the clinical management or your partner’s clinical decision-making process was determined pending the patient sobering up or diagnostics results returning normal or  “within normal limits ” before you decide on the final disposition. This means you having the final say before you discharge that patient. However, you must ask yourself these questions beforehand: Do I have all the pieces of the puzzle fitting properly before discharging the patient? Does the presentation, history, and findings fit the signed-out report given to me? 

    Typically these patients can present already diagnosed or labeled by another facility healthcare provider or simply yet by one of your very own colleagues from a different shift. This pre-packaging can easily lull you into a false sense of security. And, therein lies the legal risks & challenge(s). Given these situations unconsciously you are more apt to engage in potentially perilous clinical activities or behaviors unlike your usual methodical approach when working up your own patients. These faulty cognitive derailers like the following examples listed next can set you up for significant medical mishaps. Let’s dissect them and expose their perilous outcomes, to both, you the provider, and the patient, the recipient of your faulty or flawed narrow-framed medical decision-making shortcuts known as heuristics. Here they are: 

1. Overconfidence Bias. Beware and be careful of either you considering yourself or the other party as competently flawless as you think you are. Always be cognizant of this dangerous mindset because you or your partner may have acted on incomplete information, hunches, or very limited obtained data for that matter. This type of delusion of grandeur may result in catastrophic outcomes if we tend to believe we know more than we do, especially if we never had the “right” information or re-analyzed/re-assessed the presentation and/or signed off the patient altogether. Remember, even the best of us can have “off days” no one is perfect, especially at the end of their shifts–when they are most tired, fatigued, and very likely disengaged. 

2. Diagnosis Momentum Bias. This mindset has fooled many clinicians and accounts for many “missed diagnoses” simply because you have accepted what someone else or a few others have diagnosed the patient with. However, you may not realize or be aware that provider A, provider B, or provider C never objectively proved the patient’s recurring or for instance their unimproved symptomatology. For all practical purposes, you engaged in becoming a “clinical copycat” since the “dx” had already been made incorrectly and you went all along with it. So why reinvent the wheel? Again, clinical syndromes are not static, they evolve possibly leading to clinical instability in which you could miss a window of opportunity if fixated with the “signed-out” presented to you. 

3. Search Satisfied Bias: Here the element of premature closure surfaces because either you found or didn’t find what you were looking for in the history or physical exam. Or better yet, your cursory workup was acceptable at face value. Again, be aware not everything presents classically or the overlapping symptoms may be pointing to more than one condition. This phenomenon is very well-known and documented in many trauma-related presentations. Patients can present with different ailments/conditions that can be masked because they have a “distracting injury” or presentation for that matter. Therefore, it's best to do a secondary survey after the first one if no relevant or critical information was obtained initially. The bottom line is that you must remain vigilant and suspicious if the patient’s condition is unimproved or worsening or if alcohol is involved too. 

4. Anchoring Bias. In this situation, your colleague may have simply latched onto thinking his/her “first impression” was right or the only plausible one, therefore holding firmly onto that specific diagnosis. A very detrimental perspective or path to take when a patient’s course begins to prove inconsistent with the first diagnostic impression. This undue exerted influence or progressive development if it were to remain uncorrected, can certainly lead to possible allegations of a) failure to dx, b) failure to treat; c) failure to refer, or even d) wrongful death in some cases. This clinical inflexibility is very significant in the eyes of a judge and/or jury when the outcome of care is disastrous in terms of the outcome if there was a foreseeable medical intervention.  

5. Availability Bias. In this situation the clinician simply latches onto thinking his/her “first impression” is right thus holding firmly onto a specific diagnosis. A very detrimental stance to take when a patient’s course begins to prove inconsistent with the first diagnostic impression expected. Again this undue exerted influence or progressive development if it were to remain uncorrected, can certainly lead to possible allegations of a) failure to dx, b) failure to treat; c) failure to refer, or even d) wrongful death in some cases. This clinical inflexibility is very significant in the eyes of a jury.