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

Alan Morris Alan.Morris at IMAIL.ORG
Fri Jan 10 00:30:57 UTC 2014


Yes – harm can come from inappropriate diagnoses of psychological problems – but this is a particular case of the general issue.  Harm can come from any wrong diagnosis  - and even from suggestions of diagnoses.
I know of a young professional athlete who consoled an ER physician for sheet pain (likely a costochondritis).  The ER physician obtained an EKG and wrote "suspect pericarditis" in his note (a likely reasonable thought).  The athlete was denied medical insurance, even after producing a letter from a Professor of Cardiology (Internationally recognized EKG expert) indicating the EKG was normal and without evidence of pericarditis.  The insurance adjuster said he did not care about the professor's letter – he would not approve an application when the medical record included the word pericarditis.  The athlete never had a cardiac problem and continued  athletic activities.  I note this example of unintended consequences to illustrate the complexity and difficulty of achieving high levels of correct diagnoses.  To "see through" (diagnose) is a difficult process.

I sense that some of our comments are reflections of the human tendency to think that we, and our work, are special cases – when in fact they are just example of general principles.

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 imail.org
e-mail: alanhmorris at gmail.com

From: Amy Reinert <amy.reinert at GMAIL.COM<mailto:amy.reinert at GMAIL.COM>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Amy Reinert <amy.reinert at GMAIL.COM<mailto:amy.reinert at GMAIL.COM>>
Date: Wednesday, January 8, 2014 8:40 PM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: [IMPROVEDX] Ideas on improving rates of missed/delayed diagnoses in PCP type visits.

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.

Regards,
Amy Ruzicka, Ph.D.


On Wed, Jan 8, 2014 at 7:49 AM, Vic Nicholls <nichollsvi2 at gmail.com<mailto:nichollsvi2 at gmail.com>> 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.


http://www.medpagetoday.com/GarySchwitzer/43561
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<tel:801-507-4603>
Mobile Phone: 801-718-1283<tel:801-718-1283>
Fax: 801-507-4699<tel:801-507-4699>
e-mail: alan.morris at imail.org<mailto:alan.morris at imail.org>
e-mail: alanhmorris at gmail.com<mailto:alanhmorris at gmail.com>


On 1/6/14 7:32 PM, "Janel Hopper" <janelhopper at COMCAST.NET<mailto: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


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