There were several highlights from Day 1, including Mr. Gentry’s story and Regina Holliday’s, who both exhibited and it appears for years have shown a great courage in telling their stories. I am floored by their candor, their willingness, and the composure with which they share what happened to them, and what they have been able to do about it since.
But yesterday, the idea that stuck with me the whole time was ‘Premature Closure.’ I struggled with the idea and what it truly encompasses throughout the afternoon since the Lewis Blackburn story. To me, my initial thoughts were that it was similar to Anchoring Bias, where clinician hunker down on the initial working diagnosis and don’t properly consider alternative diagnoses. That’s something that I have seen time and time again as a physician trainee – medical school, Internal Medicine, and now GI. I know I have certainly been guilty of anchoring. For example, when I was a resident in the morning receiving sign out from the nighttime admitting resident, it was certainly easier to go with his or her working diagnosis and finish out their proposed plan rather than making sure I took a step back and agreed with it in the first place. Fortunately, I learned that taking a ‘Trust but Verify’ approach was a more prudent was to receive these handoffs, because when the nighttime resident is on their tenth admission of the night and is short on both calories and sleep, things are almost meant to fall through the cracks.
However, I don’t think Premature Closure means is perfectly equated with Anchoring Bias, or else why not just use that term? As I sat listening to the discussion and learning Lewis Blackburn’s story, I started to think that several factors other than anchoring must play a role. First, inexperience plays a part, as a surgery intern may not be as adept as their senior at recognizing an acute abdomen, or that sudden cessation of pain may signal perforation rather than improvement of ileus. But that’s just a small part. There’s a cultural aspect as well. Why was the intern the only person really rounding on the patient most days? Why did Mrs. Blackburn have to think that the chief resident was the attending? Why did the senior resident have to run in and out of a busy OR to be dismissed about a legitimate concern, maybe already too late at that point?
Lastly, I think Premature Closure really highlights the Inertia of Medicine. It’s one thing that we may anchor on a diagnosis of constipation or ileus post-op. That may make sense and make us blind to even drastic changes in vitals. But when we begin to think an issue may be occuring, sometimes it can be so hard to move an idea to the side. Why? Because it may be easier to keep going with the established diagnosis, because physicians don’t like being wrong, but mostly because we still practice in a culture where we assume 90:10 instead of 50:50. Even for the new generation of trainees, we are taught to have a broad differential in the pre-clinical and even clinical years, but when we start residency and the work piles on rapdily, we definitely feel this tension. The quote from the film that I hope can ground me and ground us as trainees is, “What’s the worst it can be?”