Over time, as we develop our practice, we store up clinical reasoning helps that can speed our decision-making for commonly reoccurring scenarios. We begin, for example, to develop rules of thumb and analogies resulting from common pattern recognition that originate from past successes. The formal term for this is heuristics. In fact, clinicians rarely use formal computations to make patient care decisions in day-to-day practice. Rather, we develop an intuitive understanding of probabilities combined with a concoction of rules of thumb, educated guesses, or mental shortcuts.
Without care, other factors can cloud our thinking. In particular, we must be mindful of our biases, cultural background, and assumptions when making clinical judgments.
Biases are rooted in our human nature and hard to avoid. We can, however, mindfully consider them as we reflect to improve practice. A few biases of importance to avoid when making clinical judgment are described here.
Premature closure is one of the most common errors. In this bias clinicians make a quick diagnosis (often based on pattern recognition), fail to consider other possible diagnoses, and stop collecting data (jump to conclusions). In fact, even the suspected diagnosis is not always confirmed by appropriate testing. A premature closure issue common in correctional nursing might be “I know this patient-he is faking this condition to get attention”.
Confirmation bias occurs when clinicians selectively accept clinical data that support a desired hypothesis and ignore data that do not. Clinicians who rely heavily on pattern recognition and become overconfident in diagnostic abilities can fall prey to premature closure and confirmation biases. If a patient is acting erratically and an officer shares a high breathalyzer reading, a nurse may settle on an alcohol intoxication diagnosis when there are also signs of a head injury.
Availability bias results in overweighing evidence that comes easily to mind. This could be recent evidence or what we perceive as meaningful events. For example, if you have ever had a legal claim against you for a particular diagnoses or clinical action, you have had heightened awareness of that diagnoses for some time afterward.
Assumptions about what is and isn’t present can also affect our thinking and judgment. A simple example can underscore how assumptions can get us tripped up. Consider this puzzle that you must solve. A donkey is tied to a 6 foot rope. A bale of hay is 8 feet away from the donkey. Without biting through the rope, how can the donkey get to the bale of hay? Answer: He just walks over to it. There is not mention that the rope is anchored to the ground. Most people hearing this story, though, assume that the donkey is tethered. Sometimes we need to see what isn’t there as well as what is there when evaluating a patient, too.
Our culture can lead to unconscious ‘habits of the mind’ that affect clinical judgment. Repeated personal experiences and cultural socialization are absorbed into our ways of thinking about the world around us. For example, over time, correctional clinicians may absorb a jaded view of inmate intentionality or the surrounding security culture of the facility. Attitudes about patient motivation can cloud our judgment and alter subjective interpretation of symptoms.
Sometimes getting over our biases, assumptions, and culture in clinical judgment is as easy as changing the questions we ask ourselves. Imagine seeing a drawing of 2 triangles a square and a circle. If you ask yourself the question “What is this?” You may answer – 2 triangles, 1 square, and 1 circle. How might that change if you ask yourself “What could this be?” Maybe the answer now is – a jack-o-lantern or a clown face. Sometimes self-questioning can break us out of our biases, assumptions, and cultural norms.
How have you seen biases, assumptions, and culture affect clinical judgment? Share your experiences in the comments section of this post.
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