Perspective: Strolling blissfully down the garden path…

“Always trust your first impression.” We’ve all heard it time and time again, but is it really true? Especially in medicine, should it ever be true?

In my review of malpractice cases over the years, one of the most common errors seen is “falling in love with one’s first impression.” It’s called “anchoring,” and can be catastrophic for both patients and physicians. Examples:

  • A 45 yo insulin dependent diabetic comes in with a blood sugar of 45 and slurred speech. Of course it’s a hypoglycemic reaction. But no, it’s a stroke.
  • A 26 yo female presents with headache for the third time in 3 months. Not unusual for this patient, with a long history of migraines. But this time it’s a ruptured aneurysm.
  • A 40 yo female tells the doctor “my ovarian cyst is really hurting this week.” Based on past history, perhaps. But this time it’s appendicitis.
  • Failing to approach each patient encounter de novo often gets physicians in trouble. Every patient deserves the benefit of a thoughtful differential diagnosis, not simply an “anchored” first impression.

    Falling in love with one’s first impression can also occur as a result of not critically appraising information received from others, such as triage nurses, receptionists, EMS personnel or even referring colleagues. If the triage nurse writes “cough” as a child’s chief complaint, and the physician doesn’t re-evaluate that, he or she might easily miss “the rest of the story:” Mom brought the child in after a week of a cold and cough, but today the child vomited, aspirated, and briefly stopped breathing. The receptionist may write “fell and hurt wrist” on the patient’s chart, but the patient’s main concern is that she also bumped her head and now has a headache. Information provided by others is not always reliable or complete.

    Educators well know that it is far more difficult to “un-teach” a procedure than to learn it the first time. It’s called “the law of primacy in education.” The law acknowledges that the first way one learns to do something will always be the “right” way, and to learn to do the same procedure another way will require overcoming a learner’s strong bias in favor of the first way. We all have experience with this. For example, in a household full of boys, I was taught to “lift the toilet seat.” Imagine how long it took my wife to teach me to “put the toilet seat down.”

    James G. Adams, MD, says, “An initial error can be propagated if not reassessed, leading to delayed recognition of serious disease or even mistaken diagnoses.” His excellent commentary on the concept of “anchoring errors” can be found on the website of the Agency for Healthcare Research and Quality. http://www.webmm.ahrq.gov/case.aspx?caseID=17 .

    Strolling blissfully down a garden path shown you by others can lead one into a bramble patch of difficulty. Physicians must practice avoiding becoming “anchored” to a first impression.

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