Every physician, regardless of their specialty, vividly remembers their experiences during grand rounds as a medical student or resident. A preceptor, senior resident, or attending physician would lead a pack of eager students and residents from room to room on the clinical ward. Suddenly, the pack would stop, and the questioning would begin.
“What are the top differential diagnoses?”
“What test do we need to order?”
These memories linger because they are how most physicians learn to practice medicine. We associate certain symptoms and signs with tests and procedures, along with the most likely diagnosis. Pattern recognition is essential to clinical care. Without it, we would be lost analyzing each presenting symptom for every patient. So we create shortcuts in our minds: patterns to associate certain symptoms or a combination of symptoms with a disease or a course of treatment.
Behavioral economists call them heuristics. They are why we instinctively remember to order certain tests and procedures in specific clinical scenarios. But they are also responsible for many of the inequities we see in health care.
Take, for example, how we diagnose appendicitis in a patient presenting with acute abdominal pain and discomfort. We normally look for two symptoms and one sign: right lower quadrant pain, vomiting or emesis, and an elevated white blood cell (WBC) count. However, of the three, the WBC is usually the most relied upon. It’s objective, obtained from a lab, and quantifiable. The other two symptoms are qualitative and subject to different interpretations.
To complicate matters further, we often interpret the two symptoms differently depending on whether the WBC is elevated. Should we encounter a patient presenting with the same aforementioned symptoms, but the WBC is within the normal range, we may interpret the pain to be less severe and the emesis to be more of an artifact than an actual symptom. But if the WBC is elevated, even with milder symptoms, we may be more comfortable diagnosing the patient with appendicitis.
What started out as three points of reference to make a clinical decision breaks down into a subjective assessment of one primary point of information through which we consider the additional two points of information only in relative terms. How this occurs varies per person. And that difference creates the variances we see in health care.
Some of this is unavoidable. A bloody cough presenting in a young, otherwise healthy male in the Ohio River basin would prompt a different workup than the same symptom in a similarly aged patient in metropolitan Baltimore. But the variances that drive disparities in health care come from heuristics outside the clinical realm.
Two physicians, one who grew up in relative privilege in suburban America and another who grew up impoverished, will have a unique set of heuristics for the same clinical condition. Sure, the medically oriented heuristics will be mostly the same, but that’s not all that swirls in the minds of physicians during a patient encounter.
Remember, a patient encounter is a brief exchange between two individuals, a physician and a patient. Most of what is initially gleaned by the physician comes from the patient verbally. In that vein, clinical medicine, regardless of how complex it may appear to be, comes down to basic communication. How we speak reflects how we think. And different socioeconomic and regional upbringings emphasize different styles of communication – even in similar circumstances. The patient encounter isn’t immune to this.
Think about two common chronic diseases, hypertension, and diabetes. Much of the management for these two conditions centers on medication compliance and lifestyle modifications. We recommend diet and exercise and adjust the medication dosage to achieve parameters we deem to be within a normal range.
When a patient’s blood pressure or blood sugar creeps too high, we default to adjusting the medication. It’s almost reflexive. But we hardly ever consider medication noncompliance, lifestyle changes, financial constraints, stress levels, or any of the myriad conditions that would affect the progression of these chronic diseases. By simplifying the complex socioeconomic patterns that drive chronic disease into a reflexive decision to adjust the medication, we overlook considerations that may be far more significant in the patient’s disease.
The solution is to think like a contrarian. Always challenge your basic assumptions to glean blind spots you might have missed, particularly for situations that might be slightly different from what you’re accustomed to. Those differences magnify the blind spots because your default tendencies, your heuristics, are looking for what’s familiar in that situation – when in reality, you should emphasize what is different.
Disparities in health care arise because we have different blind spots. Some physicians emphasize certain things over others. In the context of one clinical encounter, those differences may not matter. Maybe the patient would be better off getting a higher dose of medication, even if medication noncompliance is the real issue. But long-term, those discrepancies add up, more so for certain patients over others.
If we are serious about promoting equity in health care, then we should instead focus on improving the way we think. A slight shift in perception can go a long way.
Jay K. Joshi is a family physician.