Skip to main content

Advertisement

Log in

Judging Whether a Patient is Actually Improving: More Pitfalls from the Science of Human Perception

  • Reviews
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

Fallible human judgment may lead clinicians to make mistakes when assessing whether a patient is improving following treatment. This article provides a narrative review of selected studies in psychology that describe errors that potentially apply when a physician assesses a patient's response to treatment. Comprehension may be distorted by subjective preconceptions (lack of double blinding). Recall may fail through memory lapses (unwanted forgetfulness) and tacit assumptions (automatic imputation). Evaluations may be further compromised due to the effects of random chance (regression to the mean). Expression may be swayed by unjustified overconfidence following conformist groupthink (group polarization). An awareness of these five pitfalls may help clinicians avoid some errors in medical care when determining whether a patient is improving.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1.

Similar content being viewed by others

References

  1. Redelmeier DA, Dickinson VM. Determining whether a patient is feeling better: pitfalls from the science of human perception. J Gen Intern Med 2011;26(8):900–6.

    Article  PubMed  Google Scholar 

  2. Dana J, Loewenstein G. A social science perspective on gifts to physicians from industry. JAMA. 2003;290(2):252–5.

    Article  PubMed  Google Scholar 

  3. Steinman MA, Shlipak MG, McPhee SJ. Of principles and pens: attitudes of medicine housestaff toward pharmaceutical industry promotions. Am J Med. 2001;110:551–557.

    Article  PubMed  CAS  Google Scholar 

  4. Choudhry NK, Stelfox HT, Detsky AS. Relationships between authors of clinical practice guidelines and the pharmaceutical industry. J Am Med Assoc. 2002;287(5):612–7.

    Article  Google Scholar 

  5. Loewenstein G, Sah S, Cain DM. The unintended consequences of conflict of interest disclosure. JAMA. 2012;307(7):669–670.

    Article  PubMed  Google Scholar 

  6. Jones EE. Interpreting interpersonal behavior: The effects of expectancies. Science 1986;234(4772):41–46.

    Article  PubMed  CAS  Google Scholar 

  7. Rosenthal R, Jacobson L. Teachers’ expectancies: determinates of pupils’ IQ gains. Psychol Rep. 1966;19(1):115–8.

    Article  PubMed  CAS  Google Scholar 

  8. Rosenthal R, Fode KL. The effect of experimenter bias on the performance of the albino rat. Behav Sci. 1963 Jul;8(3):183–9.

    Article  Google Scholar 

  9. Wigal JK, Stout C, Kotses H, Creer TL, Fogle K, Gayheart L, Hatala J. Experimenter expectancy in resistance to respiratory air flow. Psychosomatic Med. 1997;59:318–22.

    CAS  Google Scholar 

  10. Leblanc VR, Brooks LR, Norma GR. Believing is seeing: the influence of a diagnostic hypothesis on the interpretation of clinical features. Acad Med. 2002 Oct;77(10):S67-9.

    Article  PubMed  Google Scholar 

  11. Lord CG, Ross L, Lepper MR. Biased assimilation and attitude polarization: the effects of prior theories on subsequently considered evidence. J Pers Soc Psychol. 1979;37(11):2098–109.

    Article  Google Scholar 

  12. Mumma GH. Effects of three types of potentially biasing information on symptom severity judgements for major depressive episode. J Clin Psychol. 2002:58;1327–45.

    Article  PubMed  Google Scholar 

  13. Gertman PM, Stackpole DA, Levenson DK, Manuel BM, Brennan RJ, Janko GM. Second opinions for elective surgery: the mandatory Medicaid program in Massachusetts. N Engl J Med. 1980;302(21):1169–74.

    Article  PubMed  CAS  Google Scholar 

  14. Epstein JI, Walsh PC, Sanfilipo F. Clinical and cost impact of second-opinion pathology: review of prostate biopsies prior to radical prostatectomy. Am J Surg Path. 1997;20(7):851–7.

    Article  Google Scholar 

  15. Newman EA, Guest AB, Helvie MA, Roubidoux MA, Chang AE, Kleer CG, Diehl KM, Cimmino VM, Pierce L, Hayes D, Newman LA, Sabel SM. Changes in surgical management resulting from case review at a breast cancer multidisciplinary tumor board. Cancer. 2006;107:2346–51.

    Article  PubMed  Google Scholar 

  16. Broom DH. Familiarity breeds neglect? Unanticipated benefits of discontinuous primary care. Fam Pract. 2003;20(5):503–7.

    Article  PubMed  Google Scholar 

  17. Jamtvedt G, Young JM, Kristoffersen DT, O’Brian MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews. 2006;2:CD000259.

  18. Claessen HFA, Boshuizen HPA. Recall of medical information by students and doctors. Med Educ. 1985;19:61–7.

    Article  PubMed  CAS  Google Scholar 

  19. Coughlin LD, Patel VL. Processing of critical information by physicians and medical students. J Med Educ. 1987;62:818–28.

    PubMed  CAS  Google Scholar 

  20. Eva KW. The aging physician: changes in cognitive processing and their impact on medical practice. Acad Med. 2002;77(10):S1-S6.

    Article  PubMed  Google Scholar 

  21. Gronlund SD, Ohrt DD, Dougherty MR, Perry JL, Manning CA. Role of memory in air traffic control. J Exp Psychol: Appl. 1998;4(3):263–280.

    Article  Google Scholar 

  22. Shachak A, Hadad-Dayagi M, Ziv A, Reis S. Primary care physicians’ use of an electronic medical record system: a cognitive task analysis. J Gen Intern Med. 2009;24(3):341–8.

    Article  PubMed  Google Scholar 

  23. Cebul RD, Love TE, Jain AK, Hebert CJ. Electronic health records and quality of diabetes care. N Engl J Med 2011;365(9):825–33.

    Article  PubMed  CAS  Google Scholar 

  24. Wimmers PF, Schmidt HG, Verkoeijen PPJL, Van de Wiel MWJ. Inducing expertise effects in clinical case recall. Med Educ. 2005;39:949–57.

    Article  PubMed  Google Scholar 

  25. Strowig S, Raskin P. Improved glycemic control in intensively treated type 1 diabetic patients using blood glucose meters with storage capacity and computer-assisted analyses. Diabetes Care. 1998;21(10):1694–8.

    Article  PubMed  CAS  Google Scholar 

  26. Patt MR, Houston TK, Jenckes MW, Sands DZ, Ford DE. Doctors who are using e-mail with their patients: a qualitative exploration. J Med Internet Res. 2003;5(2):e9.

    Article  PubMed  Google Scholar 

  27. Sharman SJ, Garry M, Jacobson JA, Loftus EF, Ditto PH. False memories for end-of-life decisions. Health Psych. 2008;27(2):291–6.

    Article  Google Scholar 

  28. Morris PE, Fritz CO. How to improve your memory. Psychologist 2006;19(10):608–611.

    Google Scholar 

  29. Martinali J, Bolman C. Brug J, van den Borne B, Bar F. A checklist to improve patient education in a cardiology outpatient setting. Patient Educ Couns. 2001;42:321–8.

    Article  Google Scholar 

  30. Sims AC. Importance of a high tracing-rate in long-term medical follow-up studies. Lancet. 1973;302(7826):433–5. OR

    Article  Google Scholar 

  31. Cox A, Rutter M, Yule B, Quinton D. Bias resulting from missing information: some epidemiological findings. Br J Prev Soc Med. 1977.;31(2):131–6.

    PubMed  CAS  Google Scholar 

  32. Berner ES, Graber ML. Over confidence as a cause of diagnostic error in medicine. Am J Med. 2008;121(5A);S2-23.

    Article  PubMed  Google Scholar 

  33. Rock I, Anson R. Illusory contours as the solution to a problem. Perception. 1979;8(6):665–81.

    Article  PubMed  CAS  Google Scholar 

  34. Dresselhaus TR, Luck J, Peabody JW. The ethical problem of false positives: a prospective evaluation of physician reporting in the medical record. J Med Ethics. 2002;28:291–4.

    Article  PubMed  CAS  Google Scholar 

  35. Szauter KM, Ainsworth MA, Holden MD, Mercado AC. Do students do what they write and write what they do? The match between the patient encounter and patient note. Acad Med. 2006;81(10 Suppl):S44-S47.

    Article  PubMed  Google Scholar 

  36. Pitts SR, Adams RP. Emergency department hypertension and regression to the mean. Ann Emerg Med. 1998;31:214–8.

    Article  PubMed  CAS  Google Scholar 

  37. Kahneman D, Tversky A. On the psychology of prediction. Psychol Rev. 1973;80(4):237–251.

    Article  Google Scholar 

  38. Tversky A, Kahneman D. Judgment under uncertainty: heuristics and biases. Science. 1974;185(4157):1124–31.

    Article  PubMed  CAS  Google Scholar 

  39. Whitney CW, Von Koroff M. Regression to the mean in treated versus untreated chronic pain. Pain 1992;50:281–5.

    Article  PubMed  CAS  Google Scholar 

  40. Afshar A, Yekta Z. Subjective improvement of the hands in sequential bilateral carpal tunnel surgery. J Plast Reconstr Aesthetic Surg. 2010;63(2):e193-4.

    Article  Google Scholar 

  41. Bland JM, Altman DG. Some examples of regression towards the mean. BMJ. 1994;309(6957):780.

    Article  PubMed  CAS  Google Scholar 

  42. Morton V, Torgerson DJ. Effects of regression to the mean on decision making in health care. BMJ. 2003;326:1083–4.

    Article  PubMed  Google Scholar 

  43. Greenwood MC, Rathi J, Hakim AJ, Scott DL, Doyle DV. Regression to the mean using the disease activity score in eligibility and response criteria for prescribing TNF-a inhibitors in adults with rheumatoid arthritis. Rheumatology. 2007;46:1165–7.

    Article  PubMed  CAS  Google Scholar 

  44. Janis IL. Victims of groupthink: a psychological study of foreign-policy decisions and fiascoes. Boston: Houghton Mifflin Co.;1972. p 277.

  45. Busse JW, Wilson K, Campbell C. Attitudes towards vaccination among chiropractic and naturopathic students. Vaccine 2008;26(49):6237–43.

    Article  PubMed  Google Scholar 

  46. Blascovich J, Ginsburg GP, Veach TL. A pluralistic explanation of choice shifts on the risk dimension. J Pers Soc Psychol. 1975 Mar;31(3):422–9.

    Article  Google Scholar 

  47. Unsworth CA, Thomas SA, Greenwood KM. Decision polarization among rehabilitation team recommendations concerning discharge housing for stroke patients. Int J Rehab Res. 1997;20;51–69.

    Article  CAS  Google Scholar 

  48. Christensen C, Larson JR, Abbott A, Ardolino A, Franz T, Pfeiffer C. Decision making of clinical teams: communication patterns and diagnostic error. Med Decis Making. 2000;20:45–50.

    Article  PubMed  CAS  Google Scholar 

  49. Schulz-Hardt S, Brodbeck FC, Mojzisch A, Kerschreiter R, Frey D. Group decision making in hidden profile situations: dissent as a facilitator for decision quality. J Personality Soc Psychol. 2006;91(6):1080–93.

    Article  Google Scholar 

  50. Soll JB, Larrick RP. Strategies for revising judgment: how (and how well) people use others' opinions. J Exp Psychol Learn Mem Cogn. 2009;35(3):780–805.

    Article  PubMed  Google Scholar 

  51. Rangel EK. Clinical ethics and the dynamics of group decision-making: applying the psychological data to decisions made by ethics committees. HEC Forum. 2009;21(2):207–28.

    Article  PubMed  Google Scholar 

  52. Ozgediz D, Roayaie K, Debas H, Schecter W, Farmer D. Surgery in developing countries: essential training in residency. Arch Surg. 2005;140:795–800.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

This project was supported by the Canada Research Chair in Medical Decision Sciences, the Canadian Institutes of Health Research, and the Sunnybrook Research Institute. We thank the following individuals for helpful comments on earlier drafts of this article: William Chan, Edward Etchells, Lee Ross, Tom MacMillan, Steven Shadowitz, John Staples, and Jacob Udell.

Conflict of Interest

The authors declare that they do not have a conflict of interest. The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Donald A. Redelmeier MD, FRCPC, MS(HSR), FACP.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Redelmeier, D.A., Dickinson, V.M. Judging Whether a Patient is Actually Improving: More Pitfalls from the Science of Human Perception. J GEN INTERN MED 27, 1195–1199 (2012). https://doi.org/10.1007/s11606-012-2097-2

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-012-2097-2

KEY WORDS

Navigation