Not Basing Your Decisions in Care on Assumptions

I recently had my eye exam. During the test when I was supposed to read the letters along the bottom line, the optometrist asked me to take my best guess for any that I couldn’t make out. Some I could not see but was still able to come up with a possible option.

There is something about our brains that wants to fill in the blurry blanks. We are not satisfied to take the portions we cannot see clearly and make our best judgment on what we truly know. Instead, we seek to bridge what we know with what we think we know.

How does this relate to patient care? Many times each day I do the clinical equivalent of the eye chart with my patients. I make assumptions - my patient is prescribed a medication, she is not taking the medication, therefore she is non-compliant. My judgment about patients starts the moment I see them as I start mentally assessing the likelihood that they have some secondary gain or how forthcoming they are going to be with their history. My mind is readily able to fill in all kinds of details that I only think I know.

The challenge is that we often consider our assumptions - the blanks we’ve filled in with our imagination - to be true. To a certain extent, this is human nature - nature abhors a vacuum and all that, but we do like the complete picture, so we will create what we don’t know. This can be an enjoyable pastime - think of the last time you were people-watching. In clinical practice, though, our suppositions can have serious consequences for us and our patients. Assumptions lead to the wrong diagnosis, wrong treatment, and can alienate us from those we are trying to help.

I am not sure we can fully train our brains to avoid this tendency. Part of the reason we do it is because sometimes we are right. However, I think about my eyeglass prescription. I hope that my guesses don’t mislead the optometrist. Just as I want to make sure my own doctor has all the information when caring for me, I want to know as much as I can about the patients I am caring for so that the choices I make are based on the best data available.

I’m not sure that the next time I’m in clinic, I won’t allow someone’s hemoglobin A1C level or the tattoo on the arm or the fact that they seem just like me to influence my assumptions. It is such an automatic reflex that I would have to consciously try to recognize what I know from what I think I know. Every once in a while my assumptions are so totally off base, so completely inaccurate that I am forced to stop and reflect. At these times, I am challenged by my automatic thinking. My hope is that I can distinguish between what I can see clearly and what I only guess I see.