Unquestioned Assumptions Can Hide Problems in Medical Practices

February 26, 2014

Decisions based upon false certainty are problematic for medical practices and it is vital that physicians actively guard against them.

Most of us are aware of two subsets of all knowledge:  what we know and what we don't know.  Generally speaking, we are clear about what belongs in each and we manage our behaviors and decisions accordingly.  If we know something, we take that as axiomatic.  If we know we don't, we seek further information before we act or decide.  It is an efficient way to operate.

We are not as aware of a third subset that is not at all benign:  what we think we know and are wrong about.  It may be that the knowledge was accurate at one time, but something has changed and we did not get the memo.  It may also be that we made an assumption based upon an incomplete understanding or set of facts and came to an erroneous conclusion. 

Either way, decisions based upon false certainty are problematic and it is vital to a successful medical practice that physicians actively guard against them.

Consider three examples of false certainties I have encountered within the last 30 days:

Case 1
Contractual provision: The answering service pages the provider on call when a patient calls in after hours.

Reality: The answering service refers all patients to the emergency room. Since physician assistants (PAs) are supposed to take the initial after-hours calls, the physicians have assumed that there have been no serious after-hours calls for the last couple of years that required escalation.

Case 2
Assumption: A neurosurgeon assumes his office manager is sending copies of each patient's post-operative report to the referring physician because he believes the office manager understands it is important both to continuing patient care and because it encourages future referrals.

Reality: The office manager is not forwarding the post-operative reports because it never occurred to her that it served any purpose.

Case 3
Incomplete fact set: Insurance coverage procured through one of the ACA marketplaces is easily identifiable, and physicians can simply choose not to take it.

Reality: If the physician has an "all plans" agreement with a carrier that offers a product on the marketplace, the physician must honor the marketplace plan. The insurance cards for marketplace plans are distinguishable, but the distinctions can be subtle. 

Insurance verification has become a significantly more serious issue since the marketplace plans have a lengthy grace period, and payments made for service rendered during the grace period may be recaptured.

It is obviously not practical to verify every presumed fact in every situation, and we will all continue to be plagued by errors in what we believe to be facts.  That awareness, however, enhances our ability to cope effectively with the reality.

Here are two ways to ensure you and your practice don't fall victim to false certainty:

1. Periodically question your assumptions. 
In Case 1, the answering service failure would have been revealed if one of the physicians had asked the PAs how many after-hours calls they received in the last few weeks.  Once the PAs had said none, the physician would have asked someone to review the answering service's logs and follow up with one or two patients.

In Case 2, the surgeon would have identified that his office was not closing the loop with referring physicians if he had contacted one or two and asked about their experience with his practice.

2. Identify reliable sources of information for highly technical information, and require them to substantiate their remarks.
Physicians are dealing with more and more complex requirements that have little or nothing to do with medical care.  That is not going to change.  Neither are practitioners going to suddenly have the time or inclination to become expert in all of these areas.

Just as physicians rely upon physician specialists and sub-specialists to provide care to their patients, they are well-served by relying upon subject matter experts in non-medical disciplines.

The obvious challenge is identifying real, as opposed to faux experts.  Here are two reliable tests:

• Discount the advice of anyone who throws out red meat to inflame the discourse.  Emotions are not facts, and people who work to elicit emotion generally do not have the facts, or all of them, on their side.

• Require citations, preferably primary, to support the advice.  People who know what they are talking about are glad to provide their sources.

The best defense against what we erroneously believe is to be aware of that subset of knowledge, to regularly test what is intuitively obvious, and to utilize subject matter experts for accurate information on complicated topics outside of our own particular expertise.