Quality in Medical Decision Making: Cost, Error, and Bias

How do we define quality in medical decisions? Missed diagnoses make headlines commonly. Yet there is a pervasive conflict among insurers, patients, and physicians when it comes to health care quality, testing, and cost. Perhaps the root of this problem is that we do not universally agree upon a definition of quality decision-making. This is a challenge with many facets; below are three.

First, most understand that errors occur in medicine regardless of vigilance, good intentions, and expertise. Also, adverse outcomes may occur without error. Defining an error based on the outcome is a mistake cognitive psychologists call outcome bias – that is, judging a decision by its eventual outcome rather than the merits of the decision at the time it was made. (For example, judging a drunk driving episode to be a perfectly acceptable decision because the driver made it home without incident). Therefore, it is unreasonable to judge decision-making quality solely by patient outcomes.

Second, tests are both imperfect (with some potential for false negative and false positive results) and expensive. To definitively “rule out” or confirm a diagnosis is far more costly than our system can tolerate, so physicians use a combination of considering the statistical likelihood of most common contenders and consideration of the “worst case scenario” – but even with a limitless budget, they often cannot prove or disprove the diagnosis with absolute certainty.

Third, emphasis on cost control and reduction of “unnecessary” testing makes these waters murkier, and incites controversy over care rationing and screening guidelines. Hindsight bias (the “you should have known it all along” inclination to see events that have already occurred as being more predictable than they were as they were unfolding) plays heavily in this arena. Patients often request tests for peace of mind. Physicians are often encourage to reduce testing, and in some organizations, must meet certain criteria (having exhausted other tests or therapies) before they can order some more expensive tests. However, insurers and courts judge whether those tests were appropriate after the outcome is already known.

It isn’t quality to order every possible test in an attempt at definitive confirmation or exclusion of all diagnostic contenders (even very rare ones), and it isn’t quality to screen folks unnecessarily. It isn’t quality to treat patients as population statistics rather than individual and unique human beings who could indeed have rare illnesses that will be devastating to them if missed.

In order to know it when we see it (and tie payment to it, as is becoming increasingly common), we will have to better define the term quality in medical decision making.

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