Hindsight is Blind: Part II

blind justice 2

The following is the second of a two-part series on retrospective judgement. You can read the first part here.

Trials and Manipulations

 

            If you asked a room full of clinicians to write down all of their fears, you would probably find an odd and variable assortment of horrors. But on nearly every list you would find some consequence of being wrong: disdain from colleagues, harm to a patient, or litigation in a malpractice lawsuit. These are the lurking specters that fill healthcare nightmares.

            The fear of punitive consequences doesn’t just affect our actions, it has spawned an entire medical malpractice industry. But is the very concept of these judicial systems based on a fallacy?

            In Part I of “Hindsight is Blind,” we discussed the concept of retrospective judgment in medicine. We showed how it is fueled by a chronic overconfidence in our (largely inaccurate) predictive ability and a lack of appreciation for how new information enhances our decision-making ability. These factors often (mis)guide us to the determination that our colleagues made a mistake, one that we would never make ourselves.

            But even after we have reached this (often flawed) conclusion, cognitive pitfalls continue to hound us.

 

But did you die?

            Imagine you are watching the same movie with your friend from Part I. Having forgiven him for the maddening “smudge” comment, you’re enjoying an action-packed cinematic adventure. But just as the film is about to reach its epic conclusion, your friend stands up and unplugs the television. The screen zaps to black. Adventure over.

            After your inevitable popcorn-throwing tirade, think back to the actions of the film’s protagonist. Were they righteous and rational? Were they the logical step in the context of the situation?

            Without seeing the outcome, you might be hesitant to judge the decision to jump a muscle car off of an impromptu ramp on a busy city street. Or give up a promotion to pursue a love interest. Or charge headlong into a gang leader’s lair.

            Knowing if the plan was a spectacular success or a blood-spattered failure might change how you feel about it. And this tendency to let the final result determine how we judge a decision has a name: outcome bias.

            So how does this translate from the silver screen to the hospital wards? I bet you guessed we have a study for that.

            A 1991 experiment presented a group of 112 practicing anesthesiologists with two sets of clinical cases. These groups of cases were identical except for the outcome: some, the anesthesiologists were told, resulted in a temporary injury to the patient while the others resulted in a permanent injury. With the outcome in mind, the anesthesiologists were asked to evaluate the appropriateness of the care each patient received.

            For the same clinical cases, anesthesiologists stated the care was appropriate much more often when they thought the clinical outcome was only a temporary injury. The opposite was also true; the physicians were much less likely to approve of care when they thought it had resulted in a permanent injury. Since the actual care itself never differed in these situations, it seems knowledge of the end result played a heavy role in how physicians felt about their colleagues’ care.

 

To not err is human

            This sliding scale of judging medical error seemed to rub Dr. Robert McNutt the wrong way. McNutt is an oncologist and the former Associate Director of Medical Informatics and Patient Safety Research at Rush University. Back in 2005, he decided to examine cases from something called the WebM&M, an anonymous, online morbidity and mortality conference presented by the Agency for Healthcare Research and Quality (AHRQ).

            Unlike prior reviewers of these cases, however, McNutt and his team blinded themselves to both the diagnosis and the patient’s outcome.

            “Cases always look different after an adverse event has occurred,” he said in an interview with Today’s Hospitalist. “All the criteria for defining errors and mistakes in medicine are hindsight-biased.”

            His results resembled those of our outcome-focused anesthesiologists: for nearly all of the cases, removing the outcome –and the predetermination of error— led the evaluating physicians to either agree with the care performed or to determine no medical error had actually occurred. His work led him to the conclusion that the quest to root out medical errors itself may have been misguided.

            “Applying these terms (like ‘mistake’ or ‘error’) is based on judgment,” he said in a follow-up commentary. “And we believe that these judgments are often flawed.”

 

 

This whole court is out of order!

            We’ve already explored the cornucopia of cognitive biases that affect retrospective judgment at every turn. But far more variables and biases come into play when we throw these concepts into another setting, the courtroom.

            The mere presence of a defendant in a courtroom implies a negative outcome and establishes an outcome bias. After all of the facts are divulged in the discovery process, everyone is like those radiologists with their MRI results in hand: hindsight biased. Since most lawyers, judges, witnesses, and juries are human, they are subject to a starting point of misguided overconfidence as they overestimate their own abilities to have seen the outcome coming.

            Now throw in a commissioning bias as paid witnesses subconsciously attempt to support the side that hired them. Then add all of the implicit biases that affect how we feel about other people: their occupation, race, gender, age, and appearance.

            The sum of these effects suggests that the social construct of medical negligence litigation is, at best, founded on the shakiest of psychological ground and, at worst, akin to judicial voodoo.

            There are, of course, ways to buffer the effects of retrospective biases. The first, and perhaps most important, is the widespread acknowledgement that they exist. Only then can we hope to protect the past from the mistakes of the present.

Author: Harrison Reed

Harrison Reed is an emergency medicine and critical care physician assistant (PA-C) in Baltimore, MD. He is the Associate Editor of the Journal for the American Academy of PAs (JAAPA) and regularly contributes to the New England Journal of Medicine's In Practice blog. He is the creator and editor of The Contralateral.

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