The Danger of Diagnosis Momentum

In November of 2021, 14-year-old Alice Tapper, daughter of well-known journalist Jake Tapper, began experiencing severe abdominal pain, chills, and vomiting. At the direction of her pediatrician, she went to her local hospital for the treatment of likely appendicitis. The hospital physicians ruled out appendicitis (because her pain was throughout her entire abdomen not just on the right side[1]), diagnosed her with a viral infection (without a diagnostic work-up including abdominal imaging such as an ultrasound or CT scan), and admitted her to the hospital for treatment of dehydration.

Over the next few days, Alice became sicker and sicker. Despite her declining health and her parents’ repeated requests, she did not have antibiotics (because antibiotics are not effective against a virus), abdominal imaging, or evaluation by a gastroenterologist. Medical staff continued to be dismayed and confused by her declining condition but never considered she had anything other than a virus.

Alice’s famous father, fearing she was close to death, used his fame and investigative skills to locate the hospital administrator’s phone number. After Jake’s conversation with the administrator, Alice was taken for an abdominal x-ray, which clearly showed she did not have a viral infection. An emergent ultrasound and CT scan revealed she had a burst appendix with bacterial fluid leaking into her abdomen. Due to days of toxic leakage into her body, Alice was severely septic and at high risk of death from organ failure. She was rushed into surgery but because her abdominal cavity was filled with infected fluid, her appendix could not be removed until the fluid was drained and the condition treated – a full 12 weeks later. In the meantime, Alice struggled to eat and function. Ultimately, after months of treatment and recovery, Alice returned to her normal state of health.

In an effort to expose inherent bias in medical professionals and the dangers of checkbox medicine, now 15-year-old Alice has bravely shared her experience in a recent op-ed.

Several forms of cognitive bias likely played a role in Alice’s misdiagnosis. Initially, given her gender and age, her reported symptoms were minimized and framed in the context of an ordinary virus instead of a potentially life-threatening bacterial infection. This is called the “framing effect.” Once framed, a missed or incorrect diagnosis is often relied upon and not questioned by other or subsequent members of the medical treatment team, something called “diagnosis momentum.” As Alice’s parents put it, “We assumed the doctors knew what they were talking about. [They] backed into a diagnosis.”

As a teenage girl, Alice likely also experienced other forms of medical bias including an unconscious bias toward interpreting women’s symptoms less severely and age bias.

Additionally, while diagnostic guidelines and diagnosis checklists are helpful in pinpointing root causes, they should not replace a physician’s medical judgment and critical thinking. Doctors must remember that patients’ symptoms do not always present in the typical or usual manner. Physicians solely relying on diagnostic guidelines or checklists when determining diagnoses is dangerous and fails to account for patients who do not have the typical symptoms. For instance, according to research into the accuracy of diagnosing acute appendicitis, a full 15% of children with appendicitis are misdiagnosed because their symptoms do not follow the expected path.

In short, diagnostic momentum can lead subsequent treating physicians to treat the initial incorrect diagnosis as a foregone conclusion instead of confirming or questioning it. This appears to be what happened with Alice. Her parents knew she did not just have a virus, “I see my child every day. I knew she was the wrong color and her belly was distended.” However, their requests for more tests were initially rejected. Given his national profile and journalistic connections, Jake was able to reach hospital leadership to intervene in Alice’s case, which undoubtedly averted a tragedy. As Jake stated, “Most people wouldn’t be able to do that.” However, the Tapper family had a clear message: “This could happen to any child at any hospital in the United States. This is not the time to be polite. You must speak up.”

This is a lesson we should all heed. Patients and their family should trust their instincts and speak up if they feel their input and requests are being discounted. It could save your or a family member’s life.

If you or a family member has suffered as a result of medical bias or checkbox medicine, we may be able to help. Talk to us.

[1] Right-sided abdominal pain is the usual presentation of appendicitis.