Crowd Wisdom, Premature psych conclusions, and harm from misdiagnosis

Dr.Will dr.will at FUSE.NET
Thu Jul 25 20:32:00 UTC 2013


Hello Deborah,

And then you add additional work the physician must do per patient
visit(EMR) taking them away from the patient and you end up with a
"misdiagnosis" because there was very little clinical time spent with the
patient due to extra work requirements.

So wrong diagnosis, but an effective billing software system so the hospital
was paid well. Seemingly at the expense of the patient.

It happens too frequently.

 Will Sawyer, MD

Solo Family Medicine

Cincinnati, Ohio

  _____  

From: Deborah Akinniyi [mailto:deborah.akinniyi at YALE.EDU] 
Sent: Thursday, July 25, 2013 2:11 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Crowd Wisdom, Premature psych conclusions, and harm
from misdiagnosis

 

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 

 

Confidentiality Note: This e-mail is intended only for the person or entity
to which it is addressed and may contain information that is privileged,
confidential or otherwise protected from disclosure. Dissemination,
distribution or copying of this e-mail or the information herein by anyone
other than the intended recipient, or an employee or agent responsible for
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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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for Improving Diagnosis in Medicine

To learn more about SIDM visit:
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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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for Improving Diagnosis in Medicine

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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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