Overconfidence Bias Leads to Misdiagnosis
On a cold, midwinter Saturday, one of Dr L’s last patients was Mrs E. She described having felt queasy and feverish over the past 24 hours and noted a black spot in the vision of her right eye.
Several of Dr L’s patients over the past week had presented with a viral infection causing nausea and vomiting, a mild fever, and sometimes a headache. It seemed to the physician that for the most part—aside from the visual complaint, which he was willing to discount—Mrs E was infected with the same virus. He recommended that she get plenty of rest and contact him again in a few days if she still wasn’t feeling better.
He did not hear from Mrs E the next week, and he did not think about her again until several months later, when he was notified that he was being sued for medical malpractice.
Was Dr L negligent?
(Discussion on next page)
Ann W. Latner, JD, is a freelance writer and attorney based in New York. She was formerly the director of periodicals at the American Pharmacists Association and editor of Pharmacy Times.
Clinical Scenario
Dr L, aged 44, was tired. This was not unusual. The primary care physician had a busy family practice with 2 other doctors and a nurse practitioner, and business was booming. Dr L had a new baby at home, and sleep was a rare commodity. It was also winter, when there seemed to be an endless stream of patients coming in with flu, sore throats, bronchitis, and the like.
Dr L and his partners took turns staffing the office on Saturdays. No one wanted to work on the weekend, so taking turns seemed the fairest option. On this particular Saturday in midwinter, the waiting room was packed with people coughing and sneezing, and Dr L was the physician on duty.
As always, he tried to give each patient a reasonable amount of time, but as the day wore on, he had to speed things up. The afternoon was winding down and there were still quite a few patients in the waiting room. One of the physician’s last patients that afternoon was Mrs E. The 65-year-old woman was a common visitor to the doctor’s office. She had borderline high blood pressure, slightly elevated blood glucose, and a variety of minor ailments for which she regularly appeared in the office.
As the physician ushered Mrs E into the examination room, he quickly exchanged pleasantries with her, hoping that he could get her in and out of the office speedily, handle the remaining 5 waiting patients, and get home in time to see his new baby.
“I don’t feel well at all, doctor,” said the patient. “I’ve been queasy since yesterday, I have a fever, and there’s a black spot in my vision in my right eye!”
Her right eye appeared normal upon a cursory visual examination, but she described a dark area in the visual field of that eye. Mrs E denied vomiting but said that she had been experiencing nausea for the past day. Her temperature measured 38.6°C.
Several of Dr L’s patients over the past week had presented with a viral infection causing nausea and vomiting, a mild fever, and sometimes a headache. It seemed to the physician that for the most part—aside from the visual complaint, which he was willing to discount—Mrs E was infected with the same virus.
“There is viral infection going around,” he told the patient, “and your symptoms are mostly consistent with that. I can’t prescribe anything for you except rest and an over-the-counter fever reducer/pain reliever if you need it. You should be feeling better within a couple of days. If you don’t feel better in a few days, give us a call, and we will take another look at you.”
The patient thanked Dr L and left the office. The physician took care of the last 5 patients in the waiting room and went home to his family for the rest of the weekend.
He did not hear from Mrs E the next week, and he did not think about her again until several months later, when he was notified that he was being sued for medical malpractice.
Specifically, Dr L was sued for misdiagnosing a retinal detachment as a viral infection. Four days after Mrs E saw Dr L, she went to an ophthalmologist, who diagnosed the loss of central vision in her right eye as a detached retina. Mrs E sustained permanent vision loss and was advised by a friend to consult a plaintiff’s attorney. The attorney looked at the medical records and concluded that Dr L had taken the “easy way out” by diagnosing a viral infection and not paying attention to the vision problem, which should have triggered an alarm, given that sudden changes in vision are often a symptom of something more serious. The attorney determined that Mrs E had a case and sued Dr L.
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Dr L met with the defense attorney provided by his medical malpractice insurance. The attorney had a medical expert review the records. After the review, the expert told the attorney that Dr L seemed to have fallen prey to overconfidence bias.
“Overconfidence bias,” explained the expert, “is when a clinician fails to recognize the significance of an unusual complaint and concentrates instead on the familiar. In this case, your client focused on the nausea and fever, complaints that he was familiar with, but ignored the less familiar visual complaint.” The attorney advised Dr L to settle the case within the limits of the medical malpractice policy. The case was settled out of court.
What’s the “Take-Home”?
Primary care physicians see numerous patients with nonspecific symptoms such as nausea and fever. Most of these patients have an acute and self-limiting viral illness. However, complaints of acute vision loss are relatively rare in general practice, and most primary care physicians have neither the training nor the equipment to properly evaluate these patients.
Ignoring the uncommon visual loss, however, was not the right approach. Instead, Dr L should have immediately referred the patient to an ophthalmologist or the emergency department (since it was the weekend), because a detached retina is a serious condition that can lead to permanent vision loss (as it did in this case).
Bottom Line – Familiar complaints can easily distract from the more unusual, but no symptom should be discredited.