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MedPage Today: Beware of 'COVID-19' Fog

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by Art Papier, MD, and Paritosh Prasad, MD, MBA, DTM&H for MedPage Today (APRIL 25, 2020)

An emergency physician colleague shared this recent experience:

A 45-year-old healthy male presented to the emergency department with a complaint of palpitations and feeling like he was going to pass out, which began while walking to his car after work. He had had 10 days of worsening shortness of breath, congestion, and generalized malaise, with a negative flu swab at urgent care 4 days ago. His wife had had upper respiratory infection symptoms that began at the same time, but she had been feeling better for several days now. The above presentation in the setting of COVID-19 just beginning to spread through New York state led me to prematurely narrow my differential diagnosis. If it weren't for the good working relationship I have with my colleagues, the final diagnosis of multiple pulmonary emboli would have been missed entirely. I'm grateful that I was at least aware of the possibility of my own cognitive errors, and that I was open to input from others, which helped me avoid a disastrous outcome in this case.

While a single diagnosis is top of mind every waking hour and permeates our brains during sleep, there is no better setup for diagnostic error. Self-awareness of our clinical decision-making process and the possibility of diagnostic error is highly relevant in these times. Availability and premature closure are biases every clinician should be aware of during this crisis.

Availability bias is defined as the propensity to put particular weight on a diagnosis because of the ease with which relevant examples come to mind. COVID-19 is not only available, it is everywhere: in the news, our thoughts, and our fears.

Premature closure occurs when the clinician fails to consider the full differential diagnosis and jumps to the first diagnosis that comes to mind. Premature closure has been likened to looking at a litter of puppies and falling in love with the first one you see without checking all the puppies.

The enormity of the current crisis and the risk to healthcare personnel is also a large factor in our biases. The decision-maker is at personal risk of becoming a seriously ill patient. Since this is a highly communicable disease, it means that clinicians will assume the patient is SARS-CoV-2 positive to protest the healthcare setting and themselves. With that said, the great challenge of clinical diagnosis in these times means we must understand pre-test and post-test probabilities based on where we are practicing.

Read further on Drs. Papier and Prasad's thoughts on diagnostic accuracy and erasing bias in the time of COVID-19 on MedPage Today.

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