AMHERST, Mass. – Diagnostic errors are very common in medicine and often come from failures of “clinical reasoning,” some of which may be related to a medical professional’s emotions, says social psychologist Linda Isbell at the University of Massachusetts Amherst. Such errors are especially prevalent when treating vulnerable and stigmatized groups such as people with mental health disorders, who disproportionately use emergency services and may evoke negative emotions.
Little is known about how to improve clinical reasoning, she adds, and even less is known about how emotional experiences contribute to diagnostic errors. Isbell has received a five-year, $1.71 million grant from the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality to study the influence of emotions on medical decision-making and diagnosis among emergency medicine staff.
She says, “People with mental health and substance-use disorders are very highly stigmatized in society. Research shows that these patients receive lower quality health care compared to people without these disorders. People who come in to an ER with complications of diabetes, for example, are less likely to be admitted if they also have a mental illness. This health disparity is a crisis in our society.”
Further, she adds, “The opioid crisis has led physicians to question people in pain and has heightened concerns that these patients might just be seeking drugs. So, people with mental health disorders may be less likely to get pain medication also.”
People with serious mental illnesses die about 10 to 20 years earlier than those without such illnesses, Isbell points out. “People are losing parents, children, spouses and other loved ones years before they should. This is an unacceptable tragedy. While there are many reasons for the earlier deaths among those with serious mental illness, we suspect one is that health care providers are affected by their negative emotions, perhaps often without their awareness or intention.”
With this grant, Isbell hopes to develop and test cognitive interventions that may improve diagnostic reasoning and reduce errors, which will lead to improved physical health care for those who suffer from mental illness. She will lead an interdisciplinary team of researchers and practitioners from social and clinical psychology, nursing, emergency medicine, and education.
“Diagnostic error is the new frontier in patient safety,” she points out. “We will all probably experience at least one diagnostic error in our lifetime, but some of us, like those with mental illnesses, are likely to experience many more. Our interdisciplinary approach to investigating this serious public health concern is a unique and important aspect of our work.”
In pilot studies for this work, Isbell interviewed attending emergency department doctors about their perceptions of patients with mental illness. “It was fairly clear in one-on-one conversations that physicians believe that there are differences in treating patients with mental illness,” she says. “Although doctors readily admit they are human and do have emotions, they often believe their emotions don’t influence how they diagnose patients. However, we know that even very experienced physicians are making diagnostic errors, which may at times be a result of their emotional experiences.”
Her new investigation will first involve qualitative interviews with emergency medicine physicians, nurses and patients in collaboration with co-investigators at Brigham and Women’s Hospital in Boston and the UMass Medical School in Worcester. Results will help her team to design controlled experiments and clinical case scenarios to explore possible effects of different emotional experiences on diagnostic reasoning and errors, as well as cognitive interventions that may reduce errors.
In these experiments, emergency physicians will be asked to assess and diagnose patient cases presented by actors in a variety of video-recorded patient-physician encounters, for example, with the viewer in an experimentally-induced angry emotional state or a calm state, and with the “patient” in the video presenting evidence of mental illness or not. Physicians’ diagnostic reasoning processes and their errors will be compared across situations.
Over the course of the study, Isbell and colleagues hope to present these “case videos” to more than 900 physicians and other emergency medicine professionals across the country recruited via an American Medical Association-licensed research and marketing company. In later phases of the work, the researchers plan to explore possible cognitive interventions for emergency medicine professionals to change their behavior.
She says, “We’ll be looking for simple techniques to change physicians’ and nurses’ default information processing, and ways to prime physicians so that they can overcome the often-automatic tendency to use categories, that is, to break the connection between anger and using categories or stereotypes. Hopefully there is a successful intervention that gets people to focus more on individual-level information rather than stereotypes, one that ultimately can be incorporated into the clinical workflow.”
Further, “I hope we will be able to recommend different cognitive and behavioral interventions to health care providers so health outcomes for people with mental illness will be significantly better than they are today. Almost everyone I talk to has a story to share about a friend or family member with mental health problems who has had, or is having, trouble getting a correct medical diagnosis or treatment. I want to change that. We need to change that.”