The Curse of Experience

In which we are reminded to be careful about when we take short cuts to diagnosis based on experience.

I had dinner with my primary care physician this week. [Yes, I have one primary care physician who has taken care of me for many years. We meet for dinner a couple of times a year to talk about business, medicine, politics, family stuff, vacations, and whatever.]

On this evening, after we’d finished our entrees, we focused on the challenges of diagnosing illnesses.

“On a Wednesday night,” he said, “one of my doctor friend’s patients, Dave, went to a major teaching hospital emergency room experiencing fever, headaches, and pain in his right leg – a sciatica type of pain, excruciating, like knives into his muscles.    The emergency room team and the ER doctor, a very prominent and highly respected physician, worked him up: physical exam, blood work, spinal tap, MRI. They couldn’t reach a diagnosis. They sent him home on crutches with no relief.

Two days later, Dave appeared on crutches my friend’s office, still experiencing the fever and white hot pain in his right leg. My friend listened to his symptoms, tapped into his on-line diagnostic data base, and came back with a diagnosis – an advanced tertiary Lyme disease.

So, my friend the doctor calls his friend, the ER doc Dave saw in  the Emergency Room, two nights before.

“Hey, Bob. Do you remember a guy you saw a couple of nights ago in the ER – the guy with the headaches and the pain in his leg.”

“Yes, I remember. We couldn’t figure it out so we sent him home while we’re thinking about it.”

“Well, you’re not going to like what I’m about to tell you. He has tertiary Lyme disease.”

Long silence on the other end of the line.  Turns out… the ER doc had recently published a paper on diagnosis of Lyme disease and he and his ER team had completely missed the diagnosis with Dave.

I was incredulous. “How could that have happened?” I asked.  “The ER doc is an expert on this disease and he missed it completely!”

“You know,” replied my primary care physician dinner companion, “you get used to seeing certain patterns of things.  You see 100 people with sore throats and 98 of them have strep and maybe 2 will have something else, so you begin to “lean” toward strep when you hear “sore throat”.  While that helps you be efficient and fast,  the chances are pretty good, going forward, that  you’ll miss the few that were something else.”

“I think that’s what happened in the ER with Dave; they heard ‘leg pain’ and ‘fever’ and immediately went off in a direction. They didn’t really take a step back and ask other questions they could have asked. My friend, his primary care doctor, didn’t have that pattern, so he could diagnose it.”

Whatever we’re selling, we can fall into the same trap.  We see a significant number of clients and symptoms and we build up experience that allows us to diagnose with a relatively small set of data points. With clients’ answers to a few questions, our experience tells us what the rest of the picture probably looks like and  allows us  to narrow things down fairly quickly, possibly to the point of a recommendation.

So, that works well in a significant number of cases and maybe that’s a good way to be efficient,  but it means that we don’t then ask other questions or run other tests that would help us see whether there were something else involved… and we misdiagnose and recommend the wrong thing.

The answer isn’t that we should ask all of those questions every time;  we don’t have time for that and it’s inefficient. There’s a lot to be said for experience guiding us and helping us take short cuts.

However, we need to be sure enough that we’re not causing significant harm by recommending the wrong thing because we took that shortcut.





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