Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Beware The Ladder of Inference


Sometimes in the care of patients, we jump to conclusions. Questioning our assumptions can improve relationships and help us make better decisions.   

Recently, one of my patients missed two scheduled appointments in a row. When I saw his name appear on my schedule again, I assumed he would again miss his scheduled appointment. What was this game he was playing? He was on a controlled medication, which requires an office visit every three months. I thought he was probably trying to make it look like he was coming in so that we’d refill his prescription and he wasn’t really interested in his health. Furthermore, I thought he was probably diverting the medication and that I’d better check his most recent urine drug screen. Soon I was so deep into this line of reasoning that I was ready to dismiss him from the practice.  


When he no-showed for the third appointment, I called to see what was going on. It turned out that he no longer had a car and was dependent on an unreliable family member for transportation. He felt embarrassed about missing his appointments and was reluctant to call and discuss it with me or the office staff. 


Why had I made assumptions about him, and how had they led me to nearly sever our relationship? Harvard business theorist Chris Argyris first described this mental process model as the ladder of inference. This is mental shortcut that starts with an assumption rooted in our own beliefs and experiences. The assumption may have blind spots that lead us up the “ladder” toward conclusions (positive or negative) and actions which are self-centered and dismiss the patient’s perspective. Taking mindful moments to evaluate how we think can improve decision making and patient-clinician relationships.  


How can we avoid the ladder of inference trap?  


1. Be aware that the ladder of inference is “wired” in all of us.  


2. Question your assumptions by asking, “Could there be something I haven’t considered?” 


3. Try to understand the patient’s perspective and circumstances before making conclusions and acting. 






This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.