Insight into chiropractic classes: Radiology
Note from Brendan: I’m in the middle of final exams, but the essay I wrote for my Bone and Joint Imaging class last week gives some insight into one of the coolest classes in the NYCC curriculum, and sends a message that I felt is important for all doctors. So here is my adaptation:
Satisfaction of search. Meaning the tendency to stop reading a radiograph after turning up one interesting finding, it comes naturally to all beginners in the field of radiology. It is but one of an extensive list of biases Indiana University School of Medicine radiologist Dr. Richard Gunderman highlights in an important 2009 article in the American Journal of Roentgenology (geek speak for the study of x-ray imagery). These biases can pose a risk to patients and create extra burden on healthcare systems, but persistent awareness of these biases truly can create a more effective physician.
From the perspective of a chiropractic student, some of these radiological biases stand out as particularly prevalent afflictions. Foremost is what Gunderman terms “availability bias,” or the tendency to diagnose a situation based on the most easily recalled information- or what was most recently studied. Particularly early on in practice, limited experience may lead to ‘favorite’ diagnoses receiving greater emphasis than deserved. Similarly, new clinicians may be tempted by “commission bias,” the perceived need to take action on every patient’s every complaint, not acknowledging when it falls outside the clinician’s realm of expertise. In this case doctors need a dose of humility, as they refer to a colleague who can more effectively address the case.
Another concern stands out as particularly notable in the modern American healthcare system, and moreso for new doctors. “Regret bias,” popularly known as defensive medicine, results from overestimating the likelihood of more severe diagnoses in order to ‘play it safe.’ This prevents stress on the clinician as a result of perceived possible missed diagnoses, and doctors and administrators consider it a guard against malpractice lawsuits. The emotional incentive toward this practice is strong, and experience is the best way to refine this balancing act.
Some widespread trends drive each of these behaviors. Education can contribute: “Satisfaction of search” may become a habit during years of schooling, where cases often isolate a single pathology or finding. This tests understanding and recognition of individual topics, but real patients are allowed to have more than one affliction. The very characteristics that motivate good doctors may contribute: independence, attention to detail, and need for time efficiency need to be kept in check by humility, honesty, flexibility and good communication.
Clinicians should also be sensitive to these biases in their fellows, and strive to minimize their effects. For example, clinical educators should be aware of the common tendency to make a diagnosis look easy in retrospect, “hindsight bias,” as this simplification may be far from reality and make the doctors in training feel… hopeless. However, acknowledging this tendency can prevent students from feeling inferior in comparison to their instructors. Here, either self-awareness or awareness of bias in other doctors can contribute to the solution.
“The treatment for the affliction of bias is knowledge,” Gunderman concludes. But it cannot simply end there. If we are our own bias patients, some at home exercises may be necessary. Let’s hope we doctors make compliant patients.
Source: Gunderman, R. “Biases in Radiologic Reasoning.” American Journal of Roentgenology. 2009 Mar;192(3): p561-4. Accessible at: http://www.ajronline.org/doi/full/10.2214/AJR.08.1220. Accessed 15 April 2014.