As fellows in oncology, we are constantly required to assimilate data, interpret diagnostic tests, decide on appropriate treatment regimens, and employ compassionate care in an increasingly truncated allotment of time. We must simultaneously juggle these responsibilities with each patient, and as we progress in our training, we hardly even notice we have 12 balls in the air at once.

Our thought processes undoubtedly become somewhat automated as we develop our thinking algorithms and we rely more and more on our gestalt assessments of patients. We are trained to treat patients based on evidence-based medicine, a term defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”

Yet, delivery of better medical care requires more from us. It requires a higher level of thinking. In fact, to be the best requires thinking about our thinking. Here, I share 3 cases that exhibit physician errors in cognition and how questioning our thinking may lead to the delivery of better care.

Recently, a 56-year-old male came to me for consultation regarding his newly diagnosed metastatic prostate cancer. He was an anxious marketing associate from the East Coast who presented to his primary care physician with increased urinary frequency, particularly at night. His prostate-specific antigen (PSA) level was found to be elevated at 4.0. He was referred to his local urologist, who recommended a transrectal ultrasound with biopsy, and shortly thereafter the patient was diagnosed with Gleason grade 6 prostate cancer. Prior to starting therapy, he was staged with a positron emission tomography—computed tomography (PET-CT) scan; although not supported by National Comprehensive Cancer Network guidelines, this is a common practice in the community.

The patient was found to have “numerous fluorodeoxyglucose—avid lesions within his osseous skeleton consistent with metastatic prostate cancer.” He presented to my office with the pathology slides, imaging report, and records from another physician noting his diagnosis of metastatic prostate adenocarcinoma. It was a busy day in the clinic, and I was behind schedule. Two patients were already anxiously awaiting their appointments. Initially, I was relieved by what seemed to be an easy consult. It was a cut-and-dried case of prostate cancer. My plan was to start androgen deprivation therapy and move on to the next patient. However, something seemed amiss. He was only 56 years old. He only had Gleason grade 6 prostate cancer. He had no family history of cancer. And yet he presents with widely metastatic disease?

I promptly called the radiologist to review the images. Interestingly, all of his “lesions” were in joint spaces and more typical of degenerative joint disease. This was only arthritis! My instinct had been correct and this patient was misdiagnosed initially. I was able to change his terminal diagnosis of metastatic prostate cancer to a case of local and potentially curable prostate cancer. The patient and his family were ecstatic, but wisely inquired, “How could this have happened?” Where had the medical decision-making gone wrong?

The difficulty in providing an explanation lies, in part, in that no true medical error occurred. It was an error in medical thinking. The radiologist viewed the images under the clinical premise that the patient was recently diagnosed with prostate cancer. He was looking for evidence of prostate cancer and he believed he found it. The radiologist had made an error in medical cognition, namely an “attribution” error. He saw lesions in the skeleton and wrongly attributed them to prostate cancer because he did not question the diagnosis and think, “What else could this be?”

In another case, an 80-year-old grandfather came to me for a consult on the biochemical recurrence of his prostate cancer. He had been diagnosed 5 years earlier and had been successfully treated with brachytherapy. His urologist had trended his PSA and after a long period of being undetectable, it had increased over the preceding 4 months with a doubling time of only 2 months. A CT scan of his abdomen revealed diffuse lymphadenopathy, particularly within the obturator nodes, a pattern typical of metastatic prostate cancer. He was referred to me for treatment of his metastatic disease.

Upon my evaluation, I noted that a serum protein electrophoresis performed 2 years prior showed a mild monoclonal gammopathy that had not been addressed. I diligently performed my evaluation, including work-up of his monoclonal gammopathy, and given the questionable diagnosis of metastatic prostate cancer, elected to refer him for excisional lymph node biopsy. Several days later I was paged by the hematopathologist, who relayed the diagnosis of lymphoplasmacytic lymphoma, or Waldenström’s macroglobulinemia. When the news had been communicated to him, the patient questioned, “How could I be mislabeled as having stage 4 cancer?” How could his trusted urologist make such a mistake?

Our 80-year-old grandfather’s urologist fell into the cognitive error of “anchoring,” or latching on to an already established diagnosis. The urologist opened our patient’s medical record and immediately read the first line of the last note entitled “prostate cancer follow-up.” When his PSA was elevated in the presence of CT-demonstrated lymphadenopathy, his first thought was prostate cancer. “Of course!” the urologist thought. He failed to challenge his own thinking and consider an alternate diagnosis.

A final case demonstrates an “availability” error, when an unusual case creates a sharp bias in medical decisionmaking. A 60-year-old female with newly diagnosed diffuse large B-cell lymphoma underwent routine outpatient chemotherapy utilizing the well-known regimen of R-CHOP (rituximab, cyclophosphamide, hydroxydaunomycin, oncovin, and prednisone). On day 4 of her chemotherapy, she developed tumor lysis syndrome, acute renal failure, and arrhythmias. She died in the intensive care unit later that day.

The attending physician, extremely distraught by the outcome of this patient, subsequently developed a new policy requiring that all of his patients undergoing initial chemotherapy with R-CHOP be admitted to the hospital. He is acutely aware of the lack of evidence to drive his decision and the additional cost, inconvenience, and potential risk of hospital-acquired infections to the patient. His personal experience has driven him to develop a sharp bias in the treatment of his patients. His poignant past experience is cognitively available to cloud future decisions.

These 3 cases demonstrate how cognitive errors can affect medical practice. As Atul Gawande, MD, MPH, writes, “There is science in what we do, yes, but also habit, intuition, and sometimes plain old guessing.” We are human, and by definition, imperfect in our nature. The acceptance of imperfection is our first step toward avoidance of the cognitive error traps. We must constantly be on guard. We must question our conclusions and thought processes. We must continually evaluate our emotions and contemplate how they may affect our assessments.

The errors of attribution, anchoring, and availability are only as strong as our negligence of them. The recognition of the potential for error and resilience to a cavalier mindset is our only insurance. To be better doctors now, and many years from now, we must continue to think about how we think.

			Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. 

Articles

As fellows in oncology, we are constantly required to assimilate data, interpret diagnostic tests, decide on appropriate treatment regimens, and employ compassionate care in an increasingly truncated allotment of time.

The Cognitive Error Paradigm

		Dr Akshat Jain (far right) during his research initiative in India

Although minor institution-specific variations exist, traditional fellowship programs in the United States are able to provide training in the sophisticated Western style of practice. Given the increasing prevalence of international immigration, however, it behooves all trainees to be culturally competent in dealing with patients from other countries.

Globally, the burden of cancer continues to grow. Nearly 14.1 million new cancer cases and 8.2 million cancer-related deaths occurred in 2012. These data reflect increases from 2008 data, which revealed that approximately 12.7 million people were diagnosed and 7.6 million died of cancer.

In the United States alone, cancer is the second-most common cause of death.

 Epidemiological evidence points to the emergence of a similar trend in developing countries. For instance, cancer and cancer-related complications are emerging as recognized major public health problems in developing countries such as India.

As of 2012, the estimated number of new cancer cases in India was approximately 1 million. Nearly 700,000 people (17% of the global population) died of the disease. Due to an aging population, cancer burden rates are projected to rise to nearly 1.7 million deaths per year by 2035.

Despite data that reveal that cancer mortality rates are decreasing in more developed countries, in resource-limited countries such as India,1 physicians face a multitude of compliance issues and societal factors that often lead to treatment failure.

After growing up in Asia, receiving medical training in Africa and the United States, and running my medical nonprofit organization, I began to see the larger picture—the “global picture.”

There are people dying of cancer and blood-related disorders around the world, and the healthcare systems in place to deal with these diseases differ widely from the healthcare system here in the United States.

As a senior fellow, I mentored a third-year medical student who visited India for a hematology/oncology rotation that went smoothly. It was time for me to take the plunge. I was curious to learn firsthand how a country of nearly 1.2 billion people

 handles its cancer care—a trip was in order.

I piloted a needs assessment project in rural India to assess the barriers that patients face when seeking continuing care for cancer once discharged from initial induction therapy. The clinical and research goals of my elective (

) were guided by the core competencies of the Accreditation Council for Graduate Medical Education

		Practice-Based Learning and Improvement

Based on my assessment, I identified the need to tackle cancer and improve patient care via more cost-effective approaches, including planned interventions and the establishment of partnerships.

Over the course of my trip, I witnessed health policy in action. During a rural health visit deep into the pockets of the desert state of Rajasthan, my colleagues and I were offered a cooked meal that was made from government-issued iron-fortified food products. I witnessed the success of this program, which is similar to other national programs that cater to over a billion people.

I also quickly learned that differences between the rural and urban settings, including political differences, can make it challenging to formulate predictions that are broadly applicable. Based on my experiences, the most commonly affected patients live in rural areas and travel to urban areas for treatment.

While working closely with the team at Sawai ManSingh Medical College, I witnessed challenging stem cell transplantation procedures in 2 patients with life-threatening aplastic anemia. This was the first time that the stem cell transplant division would perform this particular procedure. Learning about the design of the conditioning regimen, donor selection, and antibiotic prophylaxis was an eye-opening experience for me. These procedures were performed for a fraction of what they would have cost in the United States, and the outcomes were comparable, if not better, with full engraftment by the third week and no signs of graft-versus-host disease.

Overall, this international elective was a very valuable learning experience, as I became more culturally competent. I recommend that others pursue similar opportunities if possible, to gain a comprehensive picture of cancer care.

	My elective has since developed into a career. To learn more about my work with Project AGNI, please visit http://dostakshat.wix.com/akshat-jain, or contact me at ajain12@nshs.edu.

Akshat Jain, MD, MPH, is a senior hematology/oncology and stem cell transplantation fellow at the Steven and Alexandra Cohen Children’s Medical Center of New York.

				Mallath MK, Taylor DG, Badwe RA, et al. The growing burden of cancer in India: epidemiology and social context. 

				The International Agency for Research on Cancer. Latest world cancer statistics: global cancer burden rises to 14.1 million new cases in 2012: marked increase in breast cancers must be addressed. http://www.iarc.fr/en/media-centre/pr/2013/pdfs/pr223_E.pdf. Published December 12, 2013. Accessed May 12, 2014.

				American Cancer Society. Cancer facts & figures 2014. http://www.cancer.org/acs/groups/content/@research/documents/webcontent/acspc-042151.pdf. Published 2014. Accessed May 12, 2014.

				Mathew A, Varghese C, Nair MK. Estimating cancer survival in developing countries: use of reply-paid post cards to augment follow-up information. 

				Gajalakshmi CK, Shanta V. Methodology for long term follow-up of cancer cases in a developing environment. 

				India’s population 2013. IndiaOnlinePages.com website. http://www.indiaonlinepages.com/population/india-currentpopulation.html. Accessed May 7, 2014.

				Summative evaluation of competencies for 12-month clinical phase residents: global resident competency rating form. Accreditation Council for Graduate Medical Education website. https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramResources/380_SummativeEvaluation_GPM_AA_04_10_2008.pdf. Accessed May 12, 2014.

Although minor institution-specific variations exist, traditional fellowship programs in the United States are able to provide training in the sophisticated Western style of practice.

International Hematology/Oncology Elective: A Unique Learning Experience

Medical oncology can be a very demanding and taxing field. It presents its own unique challenges and some situations can be very stressful, especially when balancing personal and professional life or patient-doctor relationships. Despite the challenges, there are many successful medical oncologists in practice today. However, relatively few women have successfully practiced in the field for over 4 decades. One such incredible lady and medical oncologist, Lily Parhad Hussein, MD, has been practicing in Chicago, IL, since 1972.

In her family, Dr Hussein is a fifth-generation medical practitioner. She hails from Iraq. Her family’s medical legacy began in the 1880s, when her great-grandfather’s mother, a midwife, trained her son to be a physician. Dr Hussein’s grandfather was later trained as a physician at an American missionary school in Iran, and her father was an alumnus of the School of Medicine at Edinburgh, UK.

Dr Hussein trained at the University of Baghdad Medical School in Iraq, which was established in 1927 and is affiliated with the University of Edinburgh, and graduated in 1964. She immigrated to the United States in 1965, trained in internal medicine at the Cook County Hospital Northwestern Service, participated in a hematology fellowship program at Northwestern University and the University of Illinois at Chicago (UIC), and later trained at the oncology clinic at UIC.

In the 1960s, there were few formal fellowship programs in medical oncology, and surgeons treated most oncology patients. As new chemotherapeutic agents such as mithramycin, fluorouracil, cyclophosphamide, vincristine, and steroids became available, the separate field of medical oncology became necessary. Dr Hussein was one of the few physicians trained when the field was in its infancy. During her 42 years of practice, she has watched it evolve from lilliputian to colossal, with scientists making great strides to find cures for cancer.

In 1973, Dr Hussein began practicing at the Cook County Hospital in Chicago and started the first medical oncology clinic, which was open every Wednesday morning. She ran the clinic by herself, with guidance from her mentor. Today, there are 8 dedicated medical oncologists in this group, including Dr Hussein, and 24 separate weekly oncology clinics in operation that are visited by over 500 patients each week.

Dr Hussein has trained fellows for over 3 decades. Currently she is the senior attending physician in oncology at the John H. Stroger, Jr. Hospital of Cook County. She forms the backbone of the department. Not only does she serve as our mentor, but she is also a great cook—cakes being her specialty. Dr Hussein is a mother of 5, and grandmother of 16. Her daughter, a sixth-generation medical practitioner, is also a medical oncologist.

I spoke with Dr Hussein about her journey over the years. We discussed the challenges she faced and how she overcame them, not only surviving in the oncology field, but becoming very successful and well respected along the way.

The responses below include details that she recalled about her experiences over the years. And yes, I have yet to hear Dr Hussein utter the words, “I have not seen such a case before.” She seems to truly have seen it all!

What made you choose medical oncology as your career?

I lost several family members to cancer when I was very young, including my father who had polycythemia that evolved into acute myeloid leukemia and an aunt with breast cancer. While I was doing my internship I lost my other aunt who was also very young (40s) to ovarian cancer. It triggered a kind of frustration in me and, along with it, a challenge. I wanted to understand the field and do something for people with these diseases. So I pursued hematology and subsequently moved to medical oncology. It has been a most gratifying journey so far.

Being from Iraq, did you have to struggle to adjust to the culture in the United States?

It was not tough at all, actually. There were very few foreign medical graduates at that time and we felt very welcome. When I was growing up, Iraq was very liberal. We went biking on the streets and swimming with other children. During medical school, I started track sports for women. Because I was brought up in a liberal environment, it was not difficult to adjust here.

How do you manage stressful situations at work?

There are primarily 2 types of stressful situations I have come across at work—sad stressful and irritating stressful. The sad stressful situation happens when you get young patients with terminal cancer and you have to tell them that they will die soon. In such cases, you personalize the approach. I have seen it myself and faced it when I lost a family member who was in her 40s to cancer. I understand that it can be very difficult for the patient and the family to come to terms with the fact that they will lose a loved one at such a young age. In such cases you should put yourself in their shoes and ask yourself, “What would I like to know?” I also take note of their cultural background, their beliefs, their hopes, and take those into consideration. Most humans are spiritual, no matter what religion. Almost every religion gives rewards and hope even after you die. No religion says that death is the finish line. You touch on their spirituality, not their religion directly (unless you are comfortable doing so).

Do we have evidence that there is hope after death?

No. But we still support them in their belief to make them feel comfortable around their death.

The irritating stressful can be of 2 types: patient care-related and office-related. Sometimes a patient does not get the support and care that you want them to get from the support staff at work, be it the nurses or social workers. This can cause some frustration because you want to provide the best care to your patient without much distress. In such cases, you speak to the staff, because most people are reasonable and if the situation recurs, you do have to approach the hierarchy and you may end up making some “enemies” or people who are not so fond of you. But you need to do that for the sake of patient care. This is a battle you should never avoid. You will earn respect from your patients and coworkers because you helped with something you really did not have to help with. Most people appreciate the effort. The office-related irritating situations can happen, mostly early in your career, when you work as a part of a group or team and you don’t necessarily agree with everyone. In such a situation, pick your battles. Do not get engaged in too many situations or disagreements. There will be situations that you will not like, and if it does not affect you directly, ignore them, and just move on. Learn to avoid some things, especially workplace politics.

There are patients who are in denial or are very angry about their diagnosis. This is human nature. People have different ways of handling stress and bad news. Ask them how much they want to hear and give them time. Give patients small amounts of pertinent information at a time and see patients often. Take extra time to talk to them. Give them time to respond while in a conversation. Don’t rush them. There will be patients who will refuse curative treatments because they don’t believe they have cancer or that they can die. With such patients, you have to keep insisting but never argue with them. It is their life and they have the right to make their own decisions, but it is your job to give them all the facts they need to make that decision. With such patients, document everything you say and do, including a summary of your conversations with them.

How do you manage people who seem threatening?

These are patients who mostly are angry from within. Be polite and accommodating. Hear them out. Such people talk more during a conversation, but don’t let that intimidate you. Don’t feel scared and don’t let them feel that you are scared. Document everything you do and say, and answer all of their questions. Sometimes you may need to devote more time to these patients compared with other patients. Do that—it is usually a good investment of your time. A few patients will go someplace else to get a second opinion and return to you once they confirm what you told them already.

Don’t disapprove of this. Some people need to hear it twice. Let them, and support them. Most patients will see your efforts and eventually appreciate them and come back.

I do it very slowly and don’t give all the information at the same time. I tell patients that it is cancer but sometimes wait to tell them that it’s metastatic until the workup is complete. If they ask, I tell them the stage I suspect. I usually give them time for the truth about having cancer to sink in before going into all of the details about management. Too many facts at a time can get lost in the patient’s mind. Patients are so overwhelmed to hear that the diagnosis is cancer that sometimes they don’t hear anything else you have said. Also, sometimes patients hear what they want to. So, if you tell them good and bad, they will only remember the good and ignore the bad. Be slow but specific and document everything. You may have to see some patients more often if they have trouble adjusting to the truth, especially the prognosis.

How do you manage the workload? Maintaining quality with quantity?

This is a hard thing to do if you have a busy clinic. Sometimes the quality of notes can suffer if there are many patients. See the patient first and speak with them, examine them, and let them leave before you get to your notes. Write the major things and save it. You can come back and complete it later after clinic if you have to. When you are with the patient, try to spend most of the time looking at him or her, not looking at the computer. People feel good when you pay attention to them directly. With the electronic medical record system, you can look up your scheduled patients beforehand. If you are prepared and remember patient details when you see them, they feel that you are involved with their care. Being prepared also gives you the opportunity to read about the management options before you speak with the patient. This may require some extra time in your daily schedule in the beginning, but eventually it pays off. Once you get used to it, you just flow with your plans and patients are happy with the quality of care they get from you.

How did you keep up-to-date with the ever-changing and new treatments over the years?

Believe it or not, this was one of the easier things to do. There are a lot of journals out there, some of them are very reputable and top ones, and some of them are the so-called throwaway journals. These smaller journals have summaries of the articles that you can read. Off and on you will come across a review article, which is helpful initially. Browse the major journals for their abstracts and choose articles that you want to read fully. When you read an article, read the methods and summary of results, which will tell you if the study was well designed and what the results were. Don’t expect to remember everything. You can keep some notes with you, but you will need to go online and read every time you give some treatment you are not used to, or that is new. You can read NCCN guidelines as well when you plan patient treatments. Try to attend one major national meeting a year and attend conferences that review the national conference, because navigating the actual conference, which is very vast, may be hard and you cannot go to all sessions. Participate in tumor boards, which review not only patient care but also the latest treatment options.

Has your approach changed toward patient care over the years?

Over the years, as I have seen more, my view has become more mature. I have realized the limitations of the system and that we cannot create miracles. As young physicians, we are very enthusiastic about making a difference and helping people live longer. But sometimes we forget that quality of life can matter more than quantity for people, so you have to discuss with patients the side effects and help them choose between a toxic treatment that may make them live a little longer at the expense of quality of life, and comfort measures that may not help with lengthening life but may give them quality time with their family.

How do you think medicine has changed or evolved over the past 40 years?

Medicine has become more mechanical, though more organized. The service part has progressed immensely with new insights into genetics, tumor markers, better diagnostics, improved and new medications, and new techniques in radiation therapy. But it all has come at the expense of the art of medicine—the doctor/patient relationship has suffered. In the old days, the doctor would sit with the patient and have a discussion to make decisions based on facts from the patient’s history, physical exam, and the limited tests we had. Now we sit with a computer, staring at the screen while the patient speaks sitting on one side. We rely more on the diagnostic tests and sometimes don’t even bother to cross-check if the physical exam findings match with the radiology findings. Remember that the people reading the tests are humans, too. Also, we often bombard the patient with medical jargon about the findings on the 200 different tests he went through and the decision-making is done between the doctor and an often confused patient. That is when the patient says, “You are the doctor, tell me what to do,” and you help him or her make a decision. So, we need to make an effort to reintegrate the art of medicine with the new technology, which would make the practice of medicine more thorough and complete.

How do you manage your personal life and family with your profession?

Now that’s a tough thing to do as a woman with kids and a full-time job. Sometimes I felt that I was shortchanging one or the other, cutting short what I could have done for the job or my kids. All working professionals feel the same crunch.

My generation was the first where many women went out to work full-time. So it was a challenge to learn how to manage all of that because there was no one to tell me what to expect and do. There were no day-care centers at that time.

I had to find babysitters. Now, it is a little better with the day-care centers. I managed what I could, trying to finish early, coming late sometimes by a few minutes. If you have an understanding chief/supervisor, it’s all okay and most people do understand. But yes, sometimes it is very challenging to try to maintain both lives with a good quality. All good things come with a price. You have to be very energetic and learn multitasking. Hard work is the most important thing. You have to put in extra hours, sleep less sometimes. Eventually it pays off when you see yourself in a successful practice and your kids grow up to be successful.

It was a combination of motivation, hard work, and self-confidence. When you fail, you don’t stop. You get more motivated, get up, and try again. Failure should never lead to hopelessness. It’s not important how smart you are, it’s all about how motivated you are and how much effort you put in for what you believe in. You may need to sacrifice a few things sometimes. Accept that and move forward.

Do you have any specific advice for the graduating fellows and young oncologists?

Young, new graduates are often nervous when they start practice. My advice is to trust yourself. You have enough knowledge for a good start. Treat each patient as an individual. Don’t be too shy to say, “I don’t know, but I will check it for you.” You will not know all the answers and it is not shameful to admit that you don’t know it all. Don’t hesitate to ask someone more experienced if you need to. Don’t pressure yourself to know everything. You will never be able to know it all—I still don’t!

Medical oncology can be a very demanding and taxing field.

June 2014 | Oncology Fellows

The Cognitive Error Paradigm

International Hematology/Oncology Elective: A Unique Learning Experience

Tricks of the Trade: 4 Decades of Wisdom