How could so many medical professionals be so wrong? Fixation Error.

So first there was a set of scans and a diagnosis from one specialist determining my leg issue to be a DVT (Deep Vein Thrombosis). And then a second diagnosis and scans from a highly regarded specialist in the field, confirming the same thing. Another ultrasound weeks later to review and further confirmation. Further diagnoses over the next couple of years, all confirming the same thing – despite my continuous questioning – and then, of course, it turned out not to be DVT but a tumour…

A conversation with a good friend in the medical profession led me to a concept that helps explain this – not only in the medical profession, but also in other industries such as aviation, and in many ways touches us all in different ways.

It’s a concept known as Fixation Error.

Broadly described, Fixation Error is when a practitioner focuses solely upon one single aspect of a situation, to the detriment of perhaps more relevant or pertinent information. Other pointers, however obvious, are missed as the practitioner’s focus remains on the original diagnosis.

A good example of this is in the aviation industry and one particular case that is studied by trainee pilots – United 173 over Portland, Oregon.

In this case, the pilots were about to make the descent to the airport but became engaged in a debate as to whether the landing gear was down or not.

Just after 5pm, the plane, carrying 189 passengers, when the landing gear lowered, slightly yawed to one side and there was a thump. The crew noticed that the green landing gear light wasn’t lit. The captain of the plane radioed to air traffic control and explained that they had a landing gear problem.

The plan was to orbit the plane while the situation was assessed. The flight attendants confirmed, via a visual indicator on the wings, that the landing gear was in fact locked down.

Half an hour later the captain informed air traffic control that he planned to remain in the holding pattern for another fifteen to twenty minutes. The plane was down to 7000lbs of fuel on board,  about half the fuel they had left when they last radioed control.

The captain was in no mood to hurry the plane down. The debate about the landing gear continued. 

The captain asked his crew how much fuel they’d have left after another fifteen minutes of flying. Not enough was the reply, they’d be very low on fuel. 

At 18:07 one of the plane’s engines lost power. Six minutes later both engines had gone.

The plane was going down, wasn’t able to make an airport and crash-landed in woodland. 

Miraculously only ten people lost their lives that day.

However, no one needed to have died, as had the captain attempted to land they would have done so safely, as the landing gear was in place and functioning.

But due to fixation on the issue of landing gear, they became oblivious to the one issue that was more pressing – fuel shortage.

This is known as Fixation Error.

In the aviation industry, the concept of Fixation Error is widely discussed and analysed and has lead to change. 

Want to see this action? Try this widely used puzzle. Try and solve it.

You need to make a necklace that costs no more than 15 cents using the four chains below in the image. It costs two cents to open a link, and three cents to close it again. 

(***Solution at the bottom of the post.)

Fixation Error is rampant in the medical profession.

In my case, the original diagnosis became the fixation point. The first set of scans and diagnosis pointed to a DVT (Deep Vein Thrombosis).

I’ll always remember that day. The operator, scanning my leg, went very quiet. What is it? I enquired. She informed me that she needed to refer it to a doctor. She left the room to do that. 

When she came back I enquired again. “Well, it’s not what you think“ – meaning that she thought I thought it might be cancer.  (Oh, the irony!) “It’s a DVT”,  she said.

Human error. That much I understand and accept.

However, what should have happened next should have addressed the error. I was referred to a specialist in her field, a very highly regarded Vascular Physician at a good hospital.

This particular specialist didn’t spend much time examining my films. She read the concluding report and started to talk about DVTs and their management.

Weeks later the same specialist ordered a second set of scans was ordered her, to be done by a different organisation and another written report confirming the DVT, location and size.

I continued to talk about the pain, the lack of sleep. I even enquired about the fact that I didn’t have any of the usual symptoms of a DVT – redness and swelling. It was explained to me that I had a dual vein vascular system and the blood was finding other ways to circulate around my leg.

How could a different Medical Imaging organisation get it so wrong again? 

And how could an expert in her field, conclude for the second time (at this point the third diagnosis) that it indeed was a DVT?

Because of this chain of events, and despite my gut feeling that things weren’t right, my fate was set in stone.

And no matter what I would say to the many, many specialists that I would see over the next few years, it seems I was held prisoner to my original diagnosis.

Years later, yet another request for yet another diagnosis led to a different vascular specialist approaching things from afresh and conducting his own set of scans, and in house.

His conclusion was quick and resolute. “This isn’t a DVT. I think it’s a tumour.”

And with those words, in my heart of hearts, I knew we’d solved the puzzle.

I wasn’t angry. I was relieved. Relieved to be able to begin the path of recovery and sleep. Relieved to start the process of healing and regaining my life.

Fixation Error. I’ll be focusing more on this in a later post.

*** Did you solve the puzzle?

97% of people fail to solve it because they fixate on one solution at the expense of other potential solutions. We tend to try to solve problems by taking steps that ensure progress towards a goal. We don’t generally take steps backwards, which is what is needed here.

To solve this puzzle we must break the links in one of the chains, costing us six cents and use these three links to join the remaining chains.