Discontinuity of Care as a Cause of Dx Error

Wu, Albert awu at JHSPH.EDU
Thu May 16 23:01:34 UTC 2013


Speaking as someone who is NOT a family doctor, I can still say with confidence that there is a broad range of family physician and other primary care physicians

Many of them really play quarterback, referring to specialists when more expertise or infrastructure is needed

If they do a good job, they get to know the patient well enough to broker and advise all parties.  A tough job, admittedly.  But probably the basis behind the CBS claim

Albert Wu

From: Peggy Zuckerman <peggyzuckerman at GMAIL.COM<mailto:peggyzuckerman at GMAIL.COM>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Peggy Zuckerman <peggyzuckerman at GMAIL.COM<mailto:peggyzuckerman at GMAIL.COM>>
Date: Thursday, May 16, 2013 5:44 PM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: Discontinuity of Care as a Cause of Dx Error

As always, the single variable that is part of that ever-changing dynamic is the patient himself.  That goes to the patient/family understanding that something is amiss, that "this" is out of the norm.  The patient is naively assuming that the doctors et al speak to one another, and that they share the info, including that given by the patient.

To assume that there is communication between the specialist and the family physician, and that both parties have equal access to the other data is also naive.  Moreover, there is usually no motivation on the part of the family doctor to intervene, as the reason that the patient is seeing the specialist is due to the limitations of the family doctor. The real question here is whether the proper specialist has been recommended.  We patients ask if we need a pre-emptive diagnosis to find the proper specialist.

How hard is it to have the doctors ask, "What do think is happening here?" to the patients, and to LISTEN to the answers.  We patients have to understand that unless we are true partners in the decision-making, and educated to the maximum extent possible to do that, we will continue to be acted upon by providers, not truly cared for by those providers.

Peggy Zuckerman


On Thu, May 16, 2013 at 1:49 PM, Graber, Mark <Mark.Graber at va.gov<mailto:Mark.Graber at va.gov>> wrote:
Diagnostic error is making news these days, stimulated by the recent publications by David-Newman Toker and colleagues on malpractice claims and Hardeep Singh's work on the frequency of diagnostic error in primary care.

CBS This Morning featured a story <http://www.cbsnews.com/8301-33816_162-57584037/medical-misdiagnosis-how-to-protect-yourself> by their medical news reporter Holly Phillips that focused on not having a family physician as 'one of the major reasons'.  I'm not sure how she picked that particular angle out of the hundreds of system-related root factors that contribute, but I think she's right.  There is certainly data that shows our brains are adapted to perceive a CHANGE faster and more accurately than if the same abnormality is part of a static picture, and it seems to me related phenomena explains why we miss key diagnostic clues that are so obvious to the patient's family, as well as the diagnostic errors she's thinking about in her story relating to discontinuity in care.  I'm worried this also plays out as an unintended consequence of work-hour limitations in our hospitals - the physician doing the admission work-up will be replaced by someone else that night when your condition deteriorates.

Mark

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Peggy Zuckerman
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