Ideas on improving rates of missed/delayed diagnoses in PCP type visits.

Amy Reinert amy.reinert at GMAIL.COM
Thu Jan 9 03:40:19 UTC 2014

Victoria raises a good point about the inappropriate use of the
psychological diagnosis make in the primary care office. As a psychologist,
I firmly believe that no physician (other than a psychiatrist) should be
allowed to make a psychological diagnosis. It really should be considered
unethical. I say this for three reasons. 1.) As far as I know, and someone
please correct me if I am wrong, physicians receive insufficient education
in psychology to be able to make accurate assessments. There is also
insufficient time in the general physician-patient encounter to perform an
appropriate assessment. Is it not considered unethical in medicine to make
diagnosis outside of one's area of expertise? To do so in psychology
certainly is considered unethical. 2.) In my clinical work at a college
mental health center, a number of females presented for therapy due to
physical ailments that their physicians insisted were psychological in
nature. The physician was wrong in every single case. None of these young
women actually needed to be in therapy. Their actual conditions that I can
recall off the top of my head included ovarian cyst, compression fracture
in the spine, diverticulitis, allergy, and anemia. There were others. The
physician who missed the ovarian cyst had referred the patient to therapy
because he concluded she must have deep psychological trauma because she
complained of such pain during her transvaginal ultrasound that the
technician could not complete the test nor get any good images early in the
procedure. The cyst was discovered when it eventually burst and required
surgery. 3.) In my study on women with autoimmune disease (whose symptoms
were initially dismissed by their physicians) each woman was diagnosed as
"psych" by more than one physician before receiving a correct diagnosis--
years later.

It does seem that sometimes physicians forget that patients do become
accustomed to poor interpersonal treatment in the doctor's office. They are
sometimes overly dramatic in their presentation of symptoms because they
have gotten used to having to convince the physician that something is
really wrong with them, and they are therefore are worthy of the physicians
time. People do sometimes shut down and fail to express important
information when they become intimidated when the doctor is abrupt or seems
uninterested. Also, people who are well aware that they are sick, but who
have not yet been properly diagnosed, become weary of seeking treatment and
anxious when symptoms are such that they have to seek medical care.

I mean no disrespect to the physicians and the very difficult work that
they do. However, it is extremely important to be aware that lasting harm
does come to patients via the inappropriate "psych" diagnosis. IMHO, if the
doctor cannot figure out what is wrong, the patient should hear something
along the lines of "I'm not sure right now what is going on. The tests
aren't revealing much. Let's follow up in X months if you are not better,
and of course I will see you sooner if things get worse." The doctor could
then suggest that being chronically or seriously ill is stressful, and it
is not unusual for patients to enter therapy when dealing with the life
impacting challenges of dealing with disease, particularly when it remains
undiagnosed. Leaving the door open for a suffering patient would likely do
them a world of good. There is insufficient data to suggest that the
"psych" label is generally correct when made by a PCP.

Amy Ruzicka, Ph.D.

On Wed, Jan 8, 2014 at 7:49 AM, Vic Nicholls <nichollsvi2 at> wrote:

> I can identify with this. I had a doctor who had seen cachexia and the
> like, also figured out the first time from "normal" blood work (normal for
> ranges but not for me) that I had a nutritional anemia. The "normal" blood
> work had items showing high normal/low normal values in the appropriate
> places. Allowing a computer or a person to simply read those and not be
> able to interpret symptoms and then the blood work in light of that, was
> what caused months of delay in getting treated.
> I was able to figure it out by "google". I could figure it out by
> searching medical resources (UpToDate, ClinicalKey, Medline/Pubmed) because
> the criteria were never used by doctors. In other words, 10 doctors from
> various groups never used the correct criteria for diagnosis.
> When the rates of misdiagnosis and delayed diagnosis are from 20 to even
> 40%, we've gone past "anecdotal". The biggest item doctors are sued for are
> this. The lack of relying on the medical literature to diagnose is a
> problem.
> I can show that this issue is ignored. I've got enough links about doctors
> and hospitals hiding their heads in the sand on it. Just a few below. We're
> here to get a dialogue to see how to fix it without lawyers and people
> getting hurt.
> On top of that, claiming psych issues doesn't work. I got called bipolar
> with no evidence of mania or depression. I got labelled as anorexia nervosa
> without any evidence of excessive exercise or the diet that would be normal
> for an anorexic.
> pg 202-203, Medical Blunders by Robert Youngson and Ian Schott
> Psychiatric misdiagnosis is common. An American doctor, Robert S. Hoffman,
> blames the process on a chain of irreversible and tragic events, whereby 'a
> primary physician applies a preliminary diagnosis of mental disorder which
> is decisive in determining the patients' subsequent course. Once the stigma
> of psychiatric disorder is appplied to an individual it can be impossible
> to remove it. Of 215 psychiatric patients in America, tests revealed that
> 41 percent should probably have not been referred in the first place, 63
> percent had wholly treatable conditions. At a Manhattan psychiatric center,
> 131 patients selected at random were examined, and it was concluded that up
> to 75 per cent of them had been misdiagnosed when first admitted to the
> hospital. A principal error is to mistake signs of physical illness as
> emergent psychiatric problems. Instead of looking to practical remedies,
> which may be connected to lifestyle, emotional problems or some biochemical
> imbalance, the doctor prefers to lump what he does not understand under the
> heading of mental illness and thrust a patient into an institution, or put
> him on mind-altering drugs which may have irreversible effects.
> Dr Vikas Saini, a cardiologist and president of the Lown Institute, a
> healthcare think tank in Boston, is quoted by Reuters:
> “Most of what we do in medicine doesn’t have empirical evidence” for
> whether it works and for whom, said Saini. “Instead, it’s driven by
> anecdotal evidence and professional opinion,” which doctors who practice in
> the same area are likely to hear about and be influenced by, especially
> early in their careers.
> Victoria
> On 1/7/2014 10:49 PM, Alan Morris wrote:
>> Thank you.
>> "A retrospective Isobel analysis detected my problem by my 20s."
>> This seems to be an anecdotal example of the value of decision-support
>> tools - particularly when the clinical problem is unusual or has an
>> unusual phenotypic expression.
>> Have  a nice day.
>> Alan H. Morris, M.D.
>> Professor of Medicine
>> Adjunct Prof. of Medical Informatics
>> University of Utah
>> Director of Research
>> Director Urban Central Region Blood Gas and Pulmonary Laboratories
>> Pulmonary/Critical Care Division
>> Sorenson Heart & Lung Center - 6th Floor
>> Intermountain Medical Center
>> 5121 South Cottonwood Street
>> Murray, Utah  84157-7000, USA
>> Office Phone: 801-507-4603
>> Mobile Phone: 801-718-1283
>> Fax: 801-507-4699
>> e-mail: alan.morris at
>> e-mail: alanhmorris at
>> On 1/6/14 7:32 PM, "Janel Hopper" <janelhopper at COMCAST.NET> wrote:
>>  Hi All,
>>> Some might recall that after great delay, I was diagnosed with pernicious
>>> anemia. I think that a lot of what passes for diagnosis is BS. 5
>>> hematologists at major institutions now confirm my pernicious anemia. But
>>> some clinicians can't get their head around it since I wasn't often
>>> overtly anemic. Members of a major clinic might have trouble admitting
>>> they were wrong. Easier to call the patient crazy and slap on DXes with
>>> no laboratory verification. Physicians SAY they are going to work with
>>> patients who do some of the diagnosis lifting somehow through the
>>> Internet. My experience is that this is the very rare physician.
>>> They insist on b12 levels and are wholly uninformed about the
>>> inaccuracies of these tests.
>>> Rather than hypothesize about misdiagnosis in the abstract, I challenge
>>> any of you to do a post mortem of my 35 year saga. I'm sure other members
>>> of the Pernicious Anemia Society would also offer up their records.
>>> A retrospective Isobel analysis detected my problem by my 20s.
>>> But the physicians were (and many still are) only willing to consider the
>>> case through their limited misunderstanding--such as that overt anemia
>>> must always be present with pernicious anemia. Why check the literature
>>> since when one is highly confident?
>>> Please feel free to contact me if you are interested in my challenge or
>>> more details.
>>> Janel
>>> Sent from my iPhone
> Moderator: Lorri Zipperer Lorri at, Communication co-chair, Society
> for Improving Diagnosis in Medicine
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