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Study: A physician’s emotional state can contribute to medical errors

Patient Safety Monitor Alert, August 5, 2004

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Although the healthcare industry emphasizes the importance of addressing system problems to eradicate medical errors, organizations should also work on "refining physicians' emotional and cognitive capacities," according to new research in the July/August Annals of Family Medicine ("Preventing Errors in Clinical Practice: A Call for Self-Awareness," Vol. 2, No. 4).

Many physicians attribute mistakes in part to the interference of emotional elements, writes Francesc Borrell-Carrió, MD, of the University of Barcelona in Spain, and colleagues. The elements that can interfere with a physician's performance include the following:

• Fatigue 
• Poor clinical skills
• "Transient cognitive problems" such as lack of sleep, alcohol consumption, and drug use 
• Lack of motivation
• Rushing 
• Excessive workload 
• Hostility from patients, "especially when indirectly expressed" 
• Negative feelings toward a patient 
• Somatic discomfort

The researcher traces physician errors back to two main cognitive factors:

1. Physicians have difficulty reframing the first diagnosis that comes to mind when first examining a patient.

2. They sometimes end a clinical encounter prematurely "to avoid confronting inconsistencies, low-level decision rules, and emotions."

A "low-level" decision rule would include such conclusions as, "As soon as the patient told me, I knew what he had," or, "If the patient is satisfied with the diagnosis of another physician, why should I bother to find out more data?"

More appropriate responses would include such thoughts as, "I should look beyond early hypotheses," or, "I should always form my own criteria."

"The skill of the physician often depends on the skill in switching from one type of thinking to the other, recognizing the limits of both and knowing up to which point analogical and categorical thinking can complement each other," notes Borrell-Carrió. "We have developed a series of techniques to bring the physician closer to this learning process."

The researcher encourages physicians to develop more "emotional self-awareness" so that they can better diagnose and treat patients. For example, Borrell-Carrió suggests that physicians think along these lines:

• How might my previous experience affect my actions with this patient?
• What am I assuming about this patient that might not be true?
• What surprised me about this patient? How did I respond?
• What interfered with my ability to observe, be attentive, or be respectful with this patient?
• How could I be more present with and available to this patient?
• Were there any points at which I wanted to end the visit prematurely?

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