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Unrecognized Assumptions and Their Impact on Patient Care

concerned doctor speaking with young child patient

It was late in the evening, and my husband sounded weary over the phone. He was still working on a college store inventory, though it should have been completed hours earlier. I was surprised – after years in university business consulting, Gary could time these things almost to the minute. What had gone wrong?

Then it clicked. The language on this particular campus was American Sign Language, which required that stock levels be communicated not be calling over one’s shoulder, but by turning around and signing to the recorder, which takes longer. Gary had been tripped up by a timing assumption he hadn’t realized he was making.

We all use assumptions. They help us move forward in a world of unknowns. Good planning processes attempt to recognize and call assumptions out explicitly. It is the assumptions we don’t recognize, and don’t account for, that cause the problems.

This is particularly true when dealing with clinical care planning.

I was reminded of this the other day while looking up research on end-of-life care, and on shared decision-making. Too often, for whatever reason, conversations about patient goals and desires either don’t happen, or aren’t documented. So it isn’t surprising that a number of studies have shown that what caregivers believe patients want is often more reflective of the caregivers’ values than the patients’.

Albert Mulley and team from the Dartmouth Center for Health Care Delivery Science describe this as the misdiagnosis of patient preferences. They promote a three -step model for diagnosing preferences:

  • Adopt a mindset of scientific detachment.
  • Formulate a data-based provisional diagnosis.
  • Engage the patient in conversation and deliberation.

I would submit that, in addition to properly diagnosing preferences, we need to:

  • Document those preferences in a shared care plan.
  • Make that plan available in the right format, to the entire care team – which includes patients and patient representatives.

We can never eliminate our unrecognized assumptions and biases from care processes, but the more we share information, the less likely we are to be tripped up by those assumptions.

And when we do the right thing for patients, we win their loyalty and trust. A few weeks ago, a friend told me she was planning surgery. She is battling a rare form of cancer, on top of an even rarer form of muscular dystrophy. So I was surprised to hear she was booked into a local community hospital, rather than one of our nationally ranked academic medical centers. Her comment: “The big guys are too protocol-driven. I need a hospital and medical team that will work with me on a care plan that meets my needs.”

Apparently, listening to patients, and replacing our assumptions with their goals, is good business.



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