Doctor’s assumption bias – fact or fiction
Trudie Rogers
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, the 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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