Crowd Wisdom, Premature psych conclusions, and harm from misdiagnosis

Graber, Mark Mark.Graber at VA.GOV
Fri Jul 26 00:10:11 UTC 2013


Deborah's stories, tragic as they are, convey an incredibly important lesson for all of us interested in diagnostic error - namely that being more aware of the possibility of diagnostic error can help prevent the next one.  Acknowledging that this is an 'n' of 1 demonstration, its still great to hear that building awareness had an impact.

Pat Croskerry has argued in several of his papers that one way to reduce diagnostic error is to teach the inherent shortcomings of heuristic thinking.  I was initially unconvinced, on the grounds that these are hardwired responses, and can't be unlearned.  Deborah's ability to discover a new diagnostic error would seem to argue that we should score one in Pat's favor, although I wonder what was the more dominant influence for Deborah: knowledge of cognitive bias, or just knowledge that these errors are so common.

Mark Graber
Senior Fellow, RTI International
Founder and President, Society to Improve Diagnosis in Medicine


________________________________
From: "Dr.Will" <dr.will at FUSE.NET>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, "Dr.Will" <dr.will at FUSE.NET>
Date: Thu, 25 Jul 2013 16:32:00 -0400
To: <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Crowd Wisdom, Premature psych conclusions, and harm from misdiagnosis

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



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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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