Do Physical Therapists Make Decisions Like Doctors?

Anchoring, Availability and Attribution.

One medical student calls these the "3-A Mistakes" so she wont forget how doctors make mistakes.

In How Doctors Think Jerome Groopman, MD describes common cognitive errors that busy doctors make in diagnosing their patients.

Do physical therapists make these same mistakes?

Perhaps I should be more circumspect but I'll follow Dr. Groopman's lead and share with you how at least one physical therapist committed cognitive errors in the diagnosis of a physical therapy patient.

I'm that physical therapist.

Definitions

First, I'll define the terms Anchoring, Availability and Attribution - types of cognitive errors made by all professional decision makers and not unique to medical doctors or physical therapists.

Anchoring - is seizing upon an initial presenting symptom and making a snap judgment about the diagnosis.

My patient was a middle-aged African-American female with leg pain radiating to, but not past, the knee. Many of my patients with radicular leg pain, past the knee, have been successfully treated with lumbar traction.

My anchoring error occurred when I lumped my poor patient into a traction classification based on what I thought was radicular leg pain which I did not investigate thoroughly enough to find that the radiation stopped just above her knee - referred, but not always radicular pain.

I 'anchored' my decision to use traction based on her leg pain, assigning a high probability that she would improve after the treatment,

Availability - is estimating the probability of a diagnosis based on how easily an example of a recent patient can be brought to mind.

As I've said, many of my patients got better with spinal traction - their successes were fresh in my mind. Many on my patients with referred leg pain had initially presented with pain all the way to the foot and, with treatment, their pain had worked its way back up the leg - occasionally presenting as 'leg pain to the knee'.

My cognitive error was simply because I had many other patients who responded well to traction that my poor patient would also respond well to traction.

Because my experiences were mentally 'available' I was able to quickly decide based on a vivid memory rather than actual statistical probability.

Attribution- is similar to Confirmation bias, where information that confirms one's beliefs is highlighted and information that contradicts prior beliefs is ignored.

Since my poor patient had a referral from her orthopedic surgeon that said 'consider traction for lumbar degenerative disc disease' I easily fell into the Attribution bias trap.

I didn't examine every patient characteristic that I normally do and I 'attributed' her leg pain to a pathologic diagnosis based on a reputable source.

I should have known better.

My Poor Patient

Needless to say, my poor patient didn't get better with lumbar spinal traction - she got worse. She could barely stand up when she got off of the table and it took her ten minutes to walk out of the traction room.

What did she have?

She was in a stabilization classification.

Upon further examination, my poor patient had a mild 'instability catch' and a positive prone instability test. See the full classification criteria here (Childs et al, JOSPT, 2007 June).

She is still seeing me and doing well with a stabilization program.

So, now you know my cognitive errors.

Anyone willing to share theirs?