Physician Bias Leads to Longer Waits

Constipation, dizziness, back pain - all are common complaints in the emergency department. But they're also among the problems doctors like to treat the least. Anyone who has ever been tempted (or succumbed) to digging through the charts past weak and dizzy to get to a patient with a fracture understands.

The downside is that patients with these complaints are most likely to wait longer for treatment in the emergency department waiting room, according to a new study by emergency physicians in Australia. The researchers found that patients with these problems were less likely to be seen within recommended waiting times, a factor the authors blame on diagnosis bias.

This study concentrated on the impact triage presentation description can have on waiting times. Waiting time is an important key performance indicator of emergency department function, and is linked to funding from the state in Australia, said Martin Dutch, BMedSci, MBBS, of Melbourne Health in Australia. While our paper concentrated on physicians' preferences for specific presentations and their impact on wait time, other papers have reviewed the actual impact of individual and system biases on patient outcome for specific presentations. When placed in the context of previously published literature, it is now evident that personal and system bias can [affect] the patient at a number of stages during their engagement with the emergency medical system - at the point of triage, at the point of pickup, and at the bedside.

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Dr. Dutch and his collaborators retrospectively analyzed data from three tertiary referral emergency departments. (Acad Emerg Med 2008;15[8]:731.) In a pilot study, 25 emergency physicians identified the five most liked and five most disliked patient complaints. Using key words and phrases in the triage description, they identified cases of liked and disliked complaints, and then compared those waiting times to the waiting time for cases seen previously. They also compared the waiting times for controls and complaints with the time recommended by the Australasian College of Emergency Medicine.

In a study of 28,566 complaint-controlled pairs, they found that patients with three of the five most liked complaints (dislocations, fractures, and palpitations) waited significantly less time than the controls and were more likely to be seen within the recommended waiting times. In contrast, those with dizziness, constipation, and back pain (three of the five most disliked complaints) waited significantly longer, and were less likely to be seen within the recommended waiting period. They determined that the triage descriptions of complaints allowed emergency physicians to seek or avoid patients, depending on their preference for particular complaints.

The specialty of emergency medicine in Australia is relatively new, with the Australasian college being established in 1984, Dr. Dutch noted. As emergency physicians, we are a unique craft group, and there is growing evidence that our field of medicine attracts doctors with particular personality traits. It is only reasonable to expect that particular presentations particularly appeal to us. Anecdotally there seemed to be certain presentations that are almost universally loathed.

Figure. Anecdotally ...

Disliked Complaints

Shoulder dislocations were commonly reported as a liked presentation, and it is easy to understand why, he said. They have an unambiguous diagnosis, have objective suffering, require the laying of hands, the application of a specific craft-group skill, and have an immediate response to treatment. In sharp contrast is the chronic back pain presentation, with its multifactorial etiology, poor objective evidence of impairment, and slow response to analgesia, Dr. Dutch noted.

The study demonstrated that wait times of disliked presentations were up to 10 minutes longer than controls, while liked presentations were seen up to seven minutes earlier than controls. While our study does not investigate the clinical significance of these delays on patient outcome, it does hold a mirror to our practice, he said. It highlights that our personal preferences for specific presentations are associated with aberrant behavior patterns and in doing so can demonstrably [affect] a patient's journey through the emergency medical system.

Dr. Dutch said he hoped emergency physicians would rail against personal biases with a heightened psychological awareness about their practice. For system designers, it has lessons about limiting exposure to information not relevant in decision making at point-of-care, he added.

In an accompanying commentary (Acad Emerg Med 2008;15[10]:961), Robert E. O'Connor, MD, MPH, a professor and the chair of emergency medicine in the University of Virginia Health System in Charlottesville, pointed to disparities in health care that were documented by a 2002 Institute of Medicine report. While the IOM report dealt primarily with racial and gender disparities, several factors intrinsic to the clinical encounter may be applied to bias as it pertains to the medical condition, he wrote. Clinicians may be biased [or prejudiced] against patients with certain chief complaints, especially those that are vague in nature or frustrating to treat. … What remains unclear from the paper by Dutch et al is whether there is a subtle bias that emerges during triage assessment that influences physician assignment of priority and thus determines time to be seen.

In other words, it may be satisfying to treat a fracture or dislocation, but treating constipation offers less professional satisfaction. Would you rather provide procedural sedation, reduce a fracture, and apply a splint - or order an enema? Dr. O'Connor asked. Diagnosing the cause and treating dizziness or back pain can be frustrating for both patient and physician, he noted.

With increases in ED visits in 2003, with 3.7 million visits for fractures, 2.7 million visits for back pain, and 1.5 million visits for dizziness, Dr. O'Connor noted that if clinician bias does exist, and is reflected in the differences in waiting times, then the reasons for bias need to be elucidated. It becomes incumbent on each of us to conduct a self-appraisal of whether we are biased in our approach to selected chief complaint and to develop strategies for mitigation.

He said the Australian research reaffirms the notion that clinicians need to self-examine. Each of us has likes and dislikes in the clinical realm, but should not allow these preferences to lead to disparities in health care. In emergency medicine, we are neither the social police nor the health care regulators - we report to work to take care of patients in an unbiased, nonjudgmental manner.

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