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Doctor’s assumption bias – fact or fiction
There is a theory that doctors will behave according to their bias when treating a
patient. For instance, if a patient presents to emergency (who is known to be a drug
addict) complaining of severe pain (such as a migraine) and requesting pain relief, the
doctor will assume the patient is after Schedule 8 drugs. There is, in my view, nothing
wrong with this bias, as long as doctors recognize it and do not base their diagnosis on
this assumption, failing to properly assess the patient. A drug addict could be suffering
from a brain tumor and to miss such a diagnosis could result in a claim of negligence
Doctorre not the only professionals who could behave on their assumption bias.
Nursesand Lawyers are just as capable of doing so.
I was once involved in a trial where a GP assumed tat a wife of one of his patients was
exaggerating in relation to her husband’s conditionIn this case Mrs. Perera, the
plaintiff and wife of the deceased, attended Dr Ng’sooms with her husband who had
chicken pox. When he became worse, she requested a house call (his rooms were across
the road from their home). Dr Ng attended and advised to continue with the prescribed
The following day she attended Dr Ng’s rooms (without her husband as he was too ill to
attend) seeking advice about what to do regarding her sick husband. Dr Ng did not
assess the deceased, nor did he ask any questions of Mrs. Perera about her husband’s
condition but instead falsely reassured her. Mr Perera died the following morning of
In a subsequent meeting with the plaintiff, the defendant told her that he thought she
was exaggerating the extent of her husband’s illness.
In a more recent Supreme Court decision of Papa v Sullivan Nicholaides Pty Ltd
plaintiff was “expelled” from Sullivan Nicholaides warfarin care service (WCS)ecause
the prescribing hematologist wrongly assumed that the plaintiff was non compliant.
1. In July 2001, Antoinette Papa, at age of 45 years, underwent surgery to insert a
mechanical valve in the left size of her heart. Mrs. Papa had been diagnosed with
mitral valve incompetence. As a consequence of this surgery, Ms Papa was
required to be on long-term anti-coagulant therapy in the form of Warfarin
2. Mrs. Papa was referred to the Warfarin Care Service (WCS) at Sullivan
Nicholaides (SN) to monitor her blood clotting times
1 Nurses are required at the end of each shift to hand over patients to oncoming staff. I have personal y witnessed such
handovers where the patient is classified as a “whiner or complainer” and so when the patient complains they are not
taken seriously. Everyone is subsequently surprised when the patient col apses or dies. Many hospitals have introduced
handovers via tape recording to stop such ‘gossip’ being perpetuated.
2 Hedy Perera v Bertram Man-Fai Ng (1998) unreported District Court decision 5897/97
3. Mrs. Papa’s cardiologist had set her therapeutic INR readings at between 3.0 and
4. Mrs. Papa was monitored by WCS at Sullivan Nicholaides on 35 occasions
between 18 July 2001 and 25 February 2002. On 27 February 2002 Sullivan
Nicholaides “expelled” Mrs. Papa from the program. She was advised over the
telephone by someone at Sullivan Nicholaides that they were not able to manage
her Warfarin any more and she needed to go and see her GP. When Mrs. Papa
asked why she was told they could not tell her and that she would have to ask
her doctor. It was Mrs. Papa’s evidence that she had no idea what was going on.
Mrs. Papa’s GP was contacted and the earliest possible appointment made for
5. Mrs. Papa’s GP was contacted via telephone by a female person from Sullivan
Nicholaides on 27 February 2002. He was told by this person that Mrs. Papa’s
INR levels were erratic which they felt was due to non compliance and they
would no longer monitor her Warfarin. In evidence, the GP stated that he was
“flabbergasted” by this and did not know how to respond. It is relevant to note
here that the GP received paper copies of Mrs. Papa’s INR results, which would
arrive 3 or 4 days after the test, was performed and he had no training or
6. On 28 February 2002, Mrs. Papa consulted her GP, who slightly increased her
Warfarin dose. She was told by her GP that her INR was erratic and he referred
her to QML who provided a similar Warfarin care service. However, the
following morning, Mrs. Papa suffered a stroke which has left her significantly
His Honour stated that the question for determination was:
.”whether, according to the relevant professional and practicing standards at the time, the
defendant, when presented with this artificial mitral valve patient with a recent history of
INR instability and persistent sub-therapeutic INR’s, ought to have given advice to the
plaintiff, her GP or her cardiologist, and if so, what the content of that advice ought to have
been and when it ought to have been given.
His Honour found that a reasonable Warfarin care haematologist in the position of WCS
should have made contact with Mrs. Papa and her GP. With respect to Mrs. Papa, the
a) advise her of her INR instability and persistent sub-therapeutic levels and
reaffirm the risks associated with such readings;
b) advise her of the approach taken which was to incrementally increase the
c) advise her to consult her GP with respect to the management of risks associated
with sub-therapeutic readings at least by 22 February.
With respect to her GP, the WCS should:
d) ensure the GP was aware of Mrs. Papa’s persistent sub-therapeutic INRs;
e) advise the GP of the dosage approach;
f) reaffirm the risks associated with sub-therapeutic INR and
g) recommend that the GP investigate management of the risks associated with
these sub-therapeutic levels (including raising the prospect of other forms of
anti-coagulation in consultation with the cardiologist)
Had the above advice been provided to Mrs. Papa and her GP, His Honour found it more
likely than not that the plaintiff would have been referred to her cardiologist and she
would have acted on such referral. His Honour found that her cardiologist would have
seen her immediately and treatment commenced shortly after 22 February, which more
likely than not would have prevented Mrs. Papa sufferingtroke on 1 March 2002.
The plaintiff was awarded over $2 million in compensation
The above examples show how bias, however well intended can have a serious affect on
Are lawyers any different. Potentially no. Lawyers can show a similar bias (making
assumptions that a client understands the risks of litigation) thereby making them
My point is that any professional (medical or legal) should never second-guess the
None of us can afford to second-guess . It is too costly – in more ways than one.
4 Although this decision was appealed by Sul ivan Nicholaides, the appel ant was unsuccessful and the decision at first
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