Fallacious reasoning and complexity as root causes of clinical inertia.

BACKGROUND

The quality gap and clinical inertia are stubborn problems that are prevalent, but difficult to explain. We puzzle why conscientious practitioners, who are keenly aware of appropriate evidence based treatments, avoid initiating or intensifying treatments. This has caused some to question that there may be hidden causes for these errors in the planning of chronic care.

METHODOLOGY: A timely clue enabled the author to recognize his flawed reasoning when planning the care of two elderly women sustaining hip fracture. The sudden awareness of planning error motivated a study of the under-treatment of chronic disease. Reference to fallacy and planning error were rare in the medical literature, but fallacious reasoning best explained the author's conscious decision to withhold evidence based treatment for osteoporosis from many elderly patients.

RESULTS

Increasing awareness of cognitive error had immediate impact on the treatment of osteoporosis in nursing home residents. Similar planning errors for the care of other chronic illnesses were readily identified. These errors could be attributed not only to the author, but to other conscientious physicians involved in the patient's care as well as the patients' families. The author's observations permitted a homegrown taxonomy of fallacious reasoning and complexity as it was observed. Examples of the fallacies and complexities are presented within the context of the author's four year study.

CONCLUSIONS

Fallacy and complexity contribute to clinical inertia and planning error on a regular basis in nursing homes. Gestalt for planning error, fallacy and complexity is not widely available to physicians, and they are remarkably unaware that their own cognitive limitations and biases have unintended adverse consequences for their patients. The author proposes that study of the cognitive psychology of longitudinal care is sorely lacking in current medical training. This type of reasoning differs from diagnostic reasoning, and may utilize a different part of the brain. Training in planning error should be introduced early, and refreshed periodically, as clinicians become more highly trained. Paradoxically, training and success seems to render the practitioner progressively more resistant to recognizing his entrenched fallacious belief systems.