“Vomiting, cold.”
That was the chief complaint written next to my patient’s name.
Before entering the room, the triage nurse passingly said, “First-time mom — seems like the kid has a cold.”
I entered the room and saw a tearful mother holding her 6-month-old child. They both appeared tired.
“I wouldn’t have brought them in but…”
As a pediatrician, I hear that phrase regularly. Even before discussing what illness their child is experiencing, parents begin to justify their visit to the office.
“I didn’t want to be one of those first-time moms who freak out about everything, but something really feels wrong this time.”
Her son was drinking less and vomiting more. He was losing weight. He was dehydrated and his liver was enlarged. As I examined him, the mother nervously asked, “Is it just a bug? Maybe I overreacted.”
I think about this family frequently. Despite having identified signs of illness and fearing for her child’s well-being, she remained concerned about erring in her decision to bring her child to be evaluated. Was this shame rooted in the uncertainty that accompanies new parenthood, or was it learned from negative cues from her community or even the medical system itself?
The insecurities first-time caretakers express when discussing their children’s illnesses not only harm the family but also increase pediatric clinicians’ risk of cognitive errors in their clinical decision-making.
Clinical decision-making in medicine requires some reliance on pattern recognition and identification of illness scripts. While each patient presents differently, clinicians rely on prior experiences to identify the type of presenting illness.
Cognitive biases challenge this process. While clinicians can fall prey to any bias, framing and ascertainment biases are commonplace. Framing bias focuses on the influence created by the presentation of a scenario. This can present itself through chief complaints, initial triage, verbal handoffs, or H&P notes. Any singular piece of early information may unduly influence the clinician’s decision-making. Ascertainment bias rises from the over-valuing of any subpopulation among the total population. This includes the risk of allowing assumptions from stereotyping groups such as first-time parents, young parents, or experienced parents to disproportionately impact clinical decision-making.
For the patient I cared for, I was at risk of allowing both framing and ascertainment bias. The chief complaint included both a symptom (vomiting) and a diagnosis (cold). Being led to a diagnosis rather than arriving after completing the history can prematurely close the exploration for diagnosis. The conversation with the triage nurse also predisposed me to assume that I might be seeing a nervous first-time parent with a generally well-appearing child who likely had a viral upper-respiratory illness. I was also told this mother was a first-time parent, which can introduce the biases from my past experiences with other worried new parents.
This is not to say experience plays no role in helping parents manage their child's illness. Regardless of parents’ confidence level in managing their child’s illness, parents often struggle to triage the severity of their child’s illness accurately. Additionally, parents with lower health-literacy skills were more likely to utilize emergency services for nonurgent illnesses. While the relationship is not linear, more experience as a parent could help increase their health-literacy skills.
I sent my patient to the ER for management of dehydration. He improved, but their subsequent workup ultimately revealed an underlying metabolic disorder.
Clinicians’ cognitive bias toward first-time parents harms children. Clinicians are at higher risk for missing diagnoses in children whom they presume to be well. Parents who feel their concern was dismissed may lower trust not only in their own ability to assess their child’s illness but also in their child’s clinician in future encounters.
Parents and pediatricians are allies. It is challenging to assess illness without a clinical history, and parents can provide subtle insight into their child’s symptoms. Regardless of the child’s severity of illness, it is the pediatrician’s responsibility to discuss what is happening, what to expect, and what to do next. Amid the demands of clinical medicine, spending additional time with parents on education and anticipatory guidance can help empower them to better care for their child or future children with confidence.
How can clinicians work with their patients and families to improve their health and care? Share your experiences in the comment section.
Dr. Nishant Pandya is a pediatrician in Philadelphia, PA. He enjoys biking and rooting for the Philadelphia Phillies. Dr. Pandya is a 2023–2024 Doximity Op-Med Fellow.
Animation by Jennifer Bogartz
