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

Victoria Nicholls nichollsvi2 at GMAIL.COM
Fri Jan 10 18:45:49 UTC 2014


I will add more later, but I'm looking for is other ways that we can
solve, what I have seen from recent reports, is the #1 reason for med
mal suits: missed, delayed, diagnosis. I don't think ACA is going to
help PCP's, its just going to make them have more patients, longer
waiting times. If they are given better training/education, tools,
ways to help them make the right decision faster, with more
appropriate treatment, they can accomodate more patients. I think its
going to be a lot easier on the PCP's and specialists also. If you
don't have a patient coming back and coming back to you without the
issues getting treated or bouncing around until the problem is so bad,
no one wins. More expensive and drastic measures are required, no one
wins.

I have to say that I am not too keen on patients that don't attempt to
research 2 things: 1) healthier lifestyle and 2) taking responsibility
for their health in asking questions and doing their own legitimate
research. This means Oprah and (I don't watch TV) whatever House? or
ER? doctor show is on TV are not credible.

I believe doctors are pressed for time. I would like payments for
phone call consults, etc. I believe in my responsibility for decent
research to help my doctor out. We win as a team.


Victoria



On Fri, Jan 10, 2014 at 11:43 AM, Amy Reinert <amy.reinert at gmail.com> wrote:
> The "rule out" diagnosis used in the five axis diagnostic system is very
> effective in raising a flag that is understood to mean that there is enough
> evidence present to suspect a disorder, but more information is needed to
> reach a firm conclusion. This leaves room open for another clinician to
> reach a different diagnosis (interpret evidence differently), or to later
> retract the diagnosis without leaving a record that can later be open to
> misinterpretation.
> Interdisciplinary education and awareness generally proves to be helpful in
> advancing knowledge and identifying solutions.
>
> Victoria's comment above again raises a good point. Not all of the problems
> in US health care are systems related, although there are certainly plenty
> of systems issues to make it seem reasonable to lay all of the blame there
> and not explore other possible sources. Victoria has brought forward the
> reality that the practice of medicine is affected by social and cultural
> factors that influence clinicians, both individually and in groups. Factors
> such as clinician personality traits, cognitive bias, elitism, ego, cultural
> ignorance, power, classism-- and all the other -isms, interpersonal
> dynamics, authority status, etc., are often overlooked elements of the
> container in which medicine is practiced, but understanding of the magnitude
> of their effect, for better or worse, cannot be obtained in the laboratory.
> This is where partnering between medical science and the social sciences can
> be helpful in improving care delivery and reducing cost.
>
> Best,
>
> Amy Ruzicka, Ph.D.
>
>
> On Fri, Jan 10, 2014 at 10:22 AM, Feldman, James MD <James.Feldman at bmc.org>
> wrote:
>>
>> Strongly agree with Dr. Cosby’s suggestion that changing the terminology
>> for diagnosis is essential. Some diagnoses have confirmatory or irrefutable
>> data (pathology), syndrome/testing whereas many other diagnoses will not.
>> Provisional vs confirmed diagnosis could potentially prevent overconfidence
>> or inappropriate diagnostic certainty.
>>
>>
>>
>> One needs to make certain that all interventions to address diagnostic
>> errors are held to the same standard of EBM. One could easily see increased
>> testing/costs of care and morbidity related to false + tests or incidental
>> findings- if every patient with asthma seen in the ED is considered
>> “shortness of breath, what else could this be/worse it could be= r/o PE,
>> test for ACS and only confirmed not to have with testing = more harm.
>> Clearly there are patients placed in our Asthma Bay who are either
>> identified or missed with heart failure, PE,malignancy, airway obstruction,
>> anaphylaxis. Although one solution might be to close the Asthma Bay to
>> prevent this framing error, what effect if any would that have on these
>> errors?
>>
>>
>>
>> Jim Feldman
>>
>> Professor of Emergency Medicine
>>
>> Boston University School of Medicine
>>
>>
>>
>>
>>
>> From: Karen Cosby [mailto:kcosby40 at GMAIL.COM]
>> Sent: Friday, January 10, 2014 1:29 AM
>> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>>
>>
>> Subject: Re: [IMPROVEDX] Ideas on improving rates of missed/delayed
>> diagnoses in PCP type visits.
>>
>>
>>
>> This is a sad example not so much of medical misdiagnosis but rather an
>> inflexible and unfair legal/insurance industry.  The physician may have
>> simply asked for a consultation with a question of pericarditis that the
>> insurer failed to dismiss even with clear evidence of good health.  I was
>> rated as an insurance risk because of high blood pressure during pregnancy
>> (preeclampsia) that has had no bearing on my health since, costing me
>> thousands in insurance premiums ever since.  That's not an issue of
>> misdiagnosis as much as a problem with how medical information can be
>> misused and misunderstood.  Once again  this is an example of people
>> assuming that every diagnosis is final, absolute, and constant.  It really
>> seems to me that we need to find a language that communicates better where
>> we are in the process of diagnosis (perhaps "diagnosis under consideration",
>> diagnosis pending further evaluation, versus diagnosis established).  I have
>> been surprised to have a number of conversations with lay people who are
>> shocked that any one would challenge a diagnosis they've been given as if
>> all diagnoses are established with absolute certainty.
>>
>>
>>
>> On Thu, Jan 9, 2014 at 6:30 PM, Alan Morris <Alan.Morris at imail.org> wrote:
>>
>> 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>
>> Reply-To: Society to Improve Diagnosis in Medicine
>> <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Amy Reinert <amy.reinert at GMAIL.COM>
>> Date: Wednesday, January 8, 2014 8:40 PM
>> To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG"
>> <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>
>> 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
>> Mobile Phone: 801-718-1283
>> Fax: 801-507-4699
>> e-mail: alan.morris at imail.org
>> e-mail: alanhmorris at gmail.com
>>
>>
>> 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 ZPM1.com, Communication co-chair, Society
>> for Improving Diagnosis in Medicine
>>
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>>
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>> for Improving Diagnosis in Medicine
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