Patient experience

Swerlick, Robert A rswerli at EMORY.EDU
Tue Oct 22 23:36:31 UTC 2013

I use a similar framework but describe the "buckets" as:

1. Patients with actual current problem meaning they have a condition which causes them symptoms and/or functional impairment. These are patients with actual illness.

2. Patients with a potential future problem. I lump things like hypertension, hyperlipidemia, asymptomatic hyperglycemia, asymptomatic and undiagnosed "cancers" in this category. These are patients with the potential for developing illness in some time frame (hours, days, weeks, months, years...)

For the former, it will be much more straight forward to define diagnostic errors. For the latter, a diagnosis in someone who is not actually ill is problematic since it may be impossible to know if they will ever develop actual morbidity or mortality from whatever predisposing state they are in.

Robert A. Swerlick, MD
Alicia Leizman Stonecipher Chair of Dermatology
Professor and Chairman, Department of Dermatology
Emory University School of Medicine
From: Kohn, Michael [Michael.Kohn at UCSF.EDU]
Sent: Monday, October 21, 2013 2:30 PM
Subject: Re: [IMPROVEDX] Patient experience

Dear Colleagues,

As you know, there are different types of diagnostic errors.

In symptomatic patients, i.e. patients who are sick, we obviously want to make the right diagnosis and provide the appropriate treatment if one exists.  The two errors we make are to 1) make a wrong diagnosis and provide an inappropriate, harmful treatment, or 2) fail to make any diagnosis and fail to provide appropriate treatment.  We should acknowledge that many illnesses are best left untreated, in which case failing to make a diagnosis is fine.  Many pediatric patients brought into the ED or walk-in clinic have a SLUBI (self-limited, undiagnosed, benign illness).

In screening of asymptomatic patients, i.e. patients who are not known to be sick, we obviously want to identify pre-symptomatic disease if it is there and a useful treatment exists.  How much sense does it make to identify an untreatable pre-symptomatic disease?  The two errors we make are to 1) miss pre-symptomatic disease and therefore fail to provide useful treatment, or 2) treat pre-symptomatic disease that isn't really there or would never have caused a problem; this is "overdiagnosis".

Patients can tell stories about our failure to identify a pre-symptomatic disease that ultimately causes problems, but they can't tell stories about overdiagnosis; no individual patient knows for sure whether his treatment for pre-symptomatic disease worked or if he was treated unnecessarily for a disease that wasn't really there or would never have caused a problem, althoug we know from comparing groups of screened and unscreened patients that overdiagnosis exists.

Improving diagnosis means reducing both missed diagnosis and overdiagnosis, so I encourage the participants on this thread to read "Overdiagnosis" by H. Gilbert Welch as a counterbalance to patient stories about missed diagnoses.



Michael A. Kohn, MD, MPP

From: Lorenzo Alonso [ljalonso at UMA.ES]
Sent: Monday, October 21, 2013 9:46 AM
Subject: [IMPROVEDX] Patient experience

I find very interesting the attitude for a doctor to say "I don,t know"
instead of "inventing" diagnosis , reassuring to the patient about the
follow-up and giving him or her advices about symptoms or situations for a
quick consultation (I have a particular example with a young patient with
several visits to the ED for abdominal discomfort; after some explanations
such as "meteorism" the  patient said to the surgeon: excuse doctor but
another doctor told me that meteorism is not a diagnosis. The surgeon
asked for more test and a diagnosis of Cronh,s disease was established.
Other aspect is the active role for the patient: example ovarian cancer is
still a disease diagnosed late. I say to my patients to ask for it to the
gynecologist in a normal gynecologic visit where usually only uterine or
cervical cancer is despicted.

Lorenzo Alonso

Moderator: Lorri Zipperer Lorri at, Communication co-chair, Society for Improving Diagnosis in Medicine

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