How do doctors think – and why do we make mistakes?

How do doctors think – and why do we make mistakes?

In this article we will describe how doctors think, why we make mistakes (and how to reduce them).

The start of an assessment is very (very) important for a doctor. We need to have all of our antennae up, and use every sense – eyes, ears, nose and ‘sixth sense’.

Why? An experienced doctor, may make an initial diagnosis by looking at a patient as they enter a room based on: how they look and walk (are they short of breath? in pain? happy/sad? etc), and the first words they say. A doctor will note the patient’s appearance: his/her complexion and clothes; the tilt of the head; the movements of the eyes and mouth; the way they walk, sit or stand up; the sound of their breathing.

Thankyou for coming to see me today” is a good way to start.

Kindness and unconditional ‘love’

A good doctor will combine the great start, hawk-like observational skills, and a thorough history (and examination) with a very nebulous concept .. kindness. Remember the patient is the focus not you. Be kind to them at all times. Be forgiving and patient, showing them unconditional ‘love’ (well caring) as a parent would to a child.

They are not a biological experiment laid on to interest you. They are a real human being who is ill, with all the flaws of a real human being (are you perfect?). A doctor never judges anyone. A doctor never lies.

Virtual or face-to-face?

When we do virtual appointments on the phone, a lot of these clues are gone. This is a concern. MyHSN believes all first assessments for a new problem should be face-to-face with enough time for examination if required. Virtual may be OK (or better) for follow-up assessments.

But. Back to the question .. how does a doctor think?

More questions and examination

Doctors’ theories about what is wrong continue to evolve as they take a ‘medical history’ (this means asking questions), and then do physical examinations like listening to the heart. But research shows that most doctors already have in mind two or three possible diagnoses within minutes of meeting a patient. And thus they tend to develop hunches from very incomplete information.

This should not mean you should second guess what they want to see or hear – i.e. don’t try to disguise or over-focus on symptoms. Just be honest.

But. Are there any variations?

Variation in thinking

Not all doctors think in the same way. But it is true that all good doctors acquire this ‘first impression skill’ as they get more experienced. A good doctor is also very good at choosing a small number of important questions in the history. These are skills that a good senior doctor has; whereas a junior one is more reliant on the whole assessment, especially the medical tests. And less good doctors never gain them.

Other background information

Prior knowledge of three things is also important to the doctor who is trying to make a diagnosis, and helps ‘paint the background picture’. This includes:

• The past medical and surgical history (PMH and PSH)
• Current and previous medication. 20-30% of hospital admissions are due in part to prescribing issues
• Social and family history – e.g. where they live, and whom they live with, smoking/alcohol, and the illnesses of the generations before them.

In some cases, this knowledge actually makes the diagnosis – e.g. the current problem is a repeat or consequence of a previous illness.

Lack of access to this information is a significant hindrance, as without it there is no background picture to place the current problem in. So it leaves too much if the diagnosis to ‘gut feeling’. This is often right, but not always. For this reason, poor IT and/or lack of time for the assessment, are big issues and lead to mistakes.

How the diagnosis is made

The main role of a doctor is to diagnose the cause of the patient’s problem. This is based on:

1. Recognising ‘disease patterns’ (via questioning patients and examination)
2. Long lists of causes of those patterns (with the most common on top).

An example of a ‘disease pattern’ is: more frequent urination (weeing) with burning, combined with being tender in the lower tummy. These are symptoms of a urine infection.

If the diagnosis is not obvious in the first 5 mins, how doctors think changes. We move into ‘detective mode’ and start looking at all possibilities – ruling things out and in, using questions, examination and investigations..

Relationship with the patient

Doctors are trained to care for their patients and to treat them courteously and kindly. But it is also important for the doctor to remain slightly detached in their thinking, focussing on the use of logic, rather than emotion. ‘Friendly, kind but formal’ is a good mantra. Do not think your doctor does not like you if she/he is not over friendly.

Trust and continuity are vital

The key thing a doctor tries to build in their relationship is trust. This is a vital part of the relationship and leads to better results for the patient. If the patient does not trust the doctor, they may not return for a follow-up appointment, and make the major error of assuming ‘no news is good news’. For this reason, and also because it leads to better outcomes, it is important for a patient to stick with the same doctor, if they can and the doctor/patient relationship is a good one. Continuity is vital.

Mistakes

Doctors are humans and so make mistakes. Most mistakes are made due to:

poor communication, poor observation or arrogance.”

These are the three sins of a doctor. You can work on all three. They are fixable. It may take years. But every day you focus on them, the better doctor you will be tomorrow.

Poor communication

Communication first. The BIG one. Good communication skills, are vital for all doctors, GPs, hospital, mental health, the lot.

MyHSN has advice here on the 10 major principles of good communication. The best way to get good at it, is to practice, a lot (a lot). You will make mistakes until you are a good standard. Knowing how your current clinical setting works is more than challenging, especially as it changes from placement to placement, job to job. It is hard.

Doctors also make mistakes when their judgements about a patient are unconsciously influenced by patients they have just seen. Some common infections tend to occur in mini-outbreaks, afflicting people in a single community at the same time.

So, after a doctor sees six patients – with, say, the flu – it is normal to assume that the seventh patient who complains of similar symptoms is suffering from the same disease. This is something they must be aware of. More experienced doctors make this mistake less.

The patient can help reduce communication errors by:

• Being clear about their medical history
• Keeping a medical record
• Having an accurate list of current medication
• Bringing someone with them to appointments
• Acting as a ‘go-between’ between different doctors; especially if they perceive a doctor is struggling within the system they work in – e.g. computers not talking to each other.

Poor observation

Observation is 90% of medicine.”

That means visual, touch, smell, hearing/verbal, non-verbal, all your senses. When we fail to observe – because we are tired, or inexperienced (or rarely, lazy) – mistakes are made. You need your antennae up all the time, especially at the start of the assessment. Start observing them as soon as you can, in the waiting room if it is a clinic setting. What book or newspaper are they reading? Why?

Write all observations down. If they don’t fit, and you don’t understand them, ask some more senior to see the patient.

Arrogance

Finally .. arrogance. This is a big problem for doctors,

This is a weakness we often do not recognise .. as we are too arrogant!  !

So we need to be aware when we lack experience, or knowledge, or clinical skills. Know your limitations. In these situations, it is important that we are self-aware, and not arrogant – and ask for help from someone more experienced. Or, alternatively, we may need to refer to someone in another specialty. Again, the patient can help them by saying ‘it’s fine doc, take your time, and ask someone else if you need to’.

Simple way of reducing mistakes

There is a very simple way of reducing mistakes – get very good at being a doctor. To do that you need huge experience, time, kindness and a dedication to your patients as a primary driver in your life (as well as your family and friends). If you don’t do this, you will not enjoy being a doctor. You will resent medicine. And if you don’t enjoy it you will never be any good at it. Enjoyment and being a good doctor are intrinsically linked.

Summary

We have explained how doctors think, why we make mistakes (and how to reduce them). Have we got it right? We would really like to know how you think.