Premature psych conclusions, and harm from misdiagnosis

Bradford Winters bwinters at JHMI.EDU
Fri Jul 26 18:47:05 UTC 2013

Any hint of a psych issue seems to raise the risk of misdiagnosis. Unfortunately medical education really reinforces this bias that "it's all supratentorial" leading to dismissiveness.

Sent from my iPhone

On Jul 26, 2013, at 2:29 PM, "Lorri Zipperer" <Lorri at ZPM1.COM<mailto:Lorri at ZPM1.COM>> wrote:

Forwarded by moderator:

>>Interesting. This psych issue is dangerous as, by definition, if somebody has a mental problem the temptation is to treat whatever they tell you (symptoms) with a pinch of salt. A powerful bias has been created before you have even started. As true in life in general as in medicine.

Jason Maude
Founder and CEO Isabel Healthcare
Tel: +44 1428 644886
Tel: +1 703 879 1890<>

From: xavier prida <xprida at BAYHEARTGROUP.COM<mailto:xprida at BAYHEARTGROUP.COM>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, xavier prida <xprida at BAYHEARTGROUP.COM<mailto:xprida at BAYHEARTGROUP.COM>>
Date: Friday, 26 July 2013 13:13
Subject: Re: [IMPROVEDX] ***SPAM*** Re: [IMPROVEDX] Crowd Wisdom, Premature psych conclusions, and harm from misdiagnosis

Whether it be cognitive or visual learning or both(clinicians often need integrate both) I happened upon this piece in of all sources, Sports Illustrated, elucidating the concept of "chunking". Performance(athletic or otherwise) is dependent on a trained mind and imagery with contextual organization. [broken link removed].

From: Deborah Akinniyi [mailto:deborah.akinniyi at YALE.EDU<mailto:deborah.akinniyi at YALE.EDU>]
Sent: Thursday, July 25, 2013 2:11 PM
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.


Deborah Akinniyi

Deborah C. Akinniyi, MD, MS

Yale Internal Medicine Residency Program

MD, George Washington University, '12

MS/BS, Stanford University, '08

Email: deborah.akinniyi at<mailto:deborah.akinniyi at>, chinenye at<mailto:chinenye at>

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Lorri Zipperer, Cybrarian
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Communications Co-Chair
Society to Improve Diagnosis in Medicine
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