Crowd Wisdom, Premature psych conclusions, and harm from misdiagnosis

Deborah Akinniyi deborah.akinniyi at YALE.EDU
Thu Jul 25 18:10:52 UTC 2013


Hello everyone,

My name is Deborah Akinniyi, and I'm an internal medicine resident who
became interested in diagnostic error during my third year of medical
school after my first patient died... When he died, I wept... and I was
angry. My team said there was nothing we could do, that these things
happen, and that with patients like *him *the outcome wasn't surprising. I
didn't accept these notions, because deep inside, a gnawing feeling told me
we were wrong; despite the *type* of patient he was, or the psychiatric and
medical comorbidities he had, his death could have been prevented.

These feelings pulled and pushed me towards careful review of his case,
acceptance that even the most seasoned doctors make mistakes, and my
introduction to diagnostic error. I confirmed that we were wrong, and found
that my patient's story was an unfortunate case of delayed diagnosis,
cognitive biases, and diagnostic error proved deadly. Since then, I've
remained interested in reducing diagnostic error through various means,
including sharing my experiences with other physicians so that we can all
learn from it.

I have a case of a patient who was being "dismissed as psych" so strongly
that her inspiratory chest pain, palpitations, and sinus tachycardia were
dismissed as consequences of her pre-existing psychiatric disorders. Prior
to coming on service, I was told that she was completely fine, had no
current medical issues, and was just waiting for an inpatient psych bed. I
was told, "Don't be alarmed if she complains of chest pain... It's just the
way her anxiety presents." I was even given specific instructions not to
pursue a pulmonary embolism (PE) work-up... "She does not have a PE."

It turns out, this patient had multiple PE's. She also had a personal
history of spontaneous abortions, and a family history of blood clots.
Later, we confirmed that in addition to her pre-existing psychiatric
disorders, she has a genetic clotting disorder.

When I reflect on this case, I'm forced to realize that had I not been
aware of how common various biases can lead to delayed diagnosis and
diagnostic error, this woman may have continued to go untreated, worsening
her physical health, and her concerns may have continued to be minimized
and dismissed, worsening her mental health. I also suspect that patients
with pre-existing psychiatric disorders likely suffer from delayed and
misdiagnosis more commonly, and agree that the implications this has on the
financial burden, patient safety, mental health, physical health, and the
overall doctor-patient relationship in this group are frightening.

I plan to fully analyze this case from a diagnostic error standpoint and to
review the literature on the specific biases that affect the care of
patients with pre-existing psychiatric disorders. I plan to eventually
write a case report on this, and am sure that through that process, I'll
learn even more about diagnostic error and how to prevent it. If any of you
have experiences, articles, or papers you'd like to share, please send them
my way! Also, if you have any questions for me, or any advice to help me as
I continue through residency and develop as a physician, I'm all ears and
open for mentorship. I'm inspired by you all, and I look forward to
continuing these conversations.

Sincerely,
Deborah Akinniyi


Deborah C. Akinniyi, MD, MS
Yale Internal Medicine Residency Program
MD, George Washington University, '12
MS/BS, Stanford University, '08
Website: http://fickprinciple.wordpress.com
Email: deborah.akinniyi at yale.edu, chinenye at stanfordalumni.org

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On Wed, Jul 24, 2013 at 7:40 PM, James Navin <jnavindr at aol.com> wrote:

> absolutely true there is a reason they screen admitted mental patients for
> thyroid disease and syphilis
>
> jn
> -----Original Message-----
> From: Amy Reinert <amy.reinert at GMAIL.COM>
> To: IMPROVEDX <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> Sent: Wed, Jul 24, 2013 1:36 pm
> Subject: Crowd Wisdom, Premature psych conclusions, and harm from
> misdiagnosis
>
>  I'm coming in a little bit late to this discussion, but did want to
> respond to Dr. Bell's comment about women with history of sexual abuse
> seemingly living in the doctor's office.
>
> For my doctoral dissertation research, I conducted a study of women
> diagnosed with autoimmune disease whose symptoms had been dismissed by
> several physicians over the course of several years. All of these patients
> were dismissed as "psych" by male and female physicians alike (please note
> that they were screened for pre-existing mental disorders). Some physicians
> ran tests initially. Others declined to run tests at all. Obviously these
> women truly were ill, however, they experienced significant psychological
> harm that can reasonably be attributed to misdiagnosis or lack of
> investigation. Of course, there were also financial implications from all
> of these unproductive office visits. Too much to go into in depth here, but
> in considering the harm these patients experienced in terms of their mental
> health (being told they was nothing wrong with them when in fact their
> bodies were clearly--to them-- ill) and the worsening of their untreated
> disease, it seems that there does need to be further study of patients with
> unresolved symptoms. The results of my study also indicated that more study
> of the influencing "invisible" personal biases held by physicians is also
> in order.
>
> A.D. Ruzicka, Ph.D
>
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> Save the date: Diagnostic Error in Medicine 2013. September 22-25, 2013 in
> Chicago, IL.
> http://www.dem2013.org
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