The Psychophysics of Transition to Long Term Care

More than a decade after the publication of To Err Is Human, cognitive error remains a mystery to physicians. Competent and conscientious physicians rarely recall making a single cognitive error, yet this must be central to the explanation for inappropriate physician nonadherence to evidence-based guidelines. Published information regarding cognitive error in the medical literature is scarce and widely scattered. We do know that cognitive error is induced by complexity, duress, and uncertainty, conditions that regularly confront long term care physicians when they assume care of a new patient at the skilled nursing facility. Negative attitudes and low expectations of care are common among new patients and families. This is compounded when care is assumed by an unfamiliar physician. The initial disquiet and negative misconceptions of patients and families regularly make the transition one of the most error-prone events in medical practice. On the brighter side, the transition provides an excellent opportunity to study cognitive error. Cognitive errors at transition typically begin with a decision to avoid mention of necessary changes to flawed treatment plans already in effect. This is done as a temporary measure to avoid further stressing the patient and family. But what appears to be an ideal compromise is a risky option and should be avoided. Evading the issue introduces long-term risk to the patient. In addition, although it is seldom acknowledged, evading change often has a negative impact on local standards of care. Five cognitive principles are presented as root causes of cognitive error. Six contextual factors are identified that are endemic to nursing home practice, making the physician even more error prone. Because mistrust is central to dysfunctional decision making at the transition, strategies are presented to expedite gaining trust. This article makes the case for adding training in the cognitive psychology of medical decision making to core requirements for certification in medical direction.