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

Vic Nicholls nichollsvi2 at GMAIL.COM
Sat Jan 11 03:43:52 UTC 2014

Dr. Gordon,

Thank you so much for this.

I know this might be going out on a limb for the MD's here, but do you
all believe that patients' expectation of a diagnosis, leads one to give
them something, even if it is incorrect? Like giving antibiotics for the
flu? Maybe that is an avenue we need to think about: how do we manage
patient expectations so that they're not "preconditioned", or other
practioners only looking at ICD-9/CPT codes and going 'set in stone' vs.


On 1/10/2014 11:22 AM, David Gordon, M.D. wrote:
> Victoria,
> I think your comments are incredibly important. Our medical system (as well as our medicolegal system) does tolerate uncertainty and that this comes to the detriment of quality diagnosis. I think the forces that influence physicians are both intrinsic and extrinsic.
> As far as intrinsic influences, there was a very interesting comment made in Weed & Weed's article "Diagnosing diagnostic failure" in Mark's new journal  Diagnosis:
> "Humans have limited tolerance for uncertainty. Medical students thus learn to avoid doubt, and they too often fail to develop awareness of the imperfect fit between medical knowledge and the enormous variability of individual patients. In this way, they acquire unwarranted confidence in their developing clinical judgment. They learn to display this false confidence to colleagues and patients. Physicians are thus socialized into a lack of scientific integrity, a condition that permeates medical practice."
> I think there is truth to this - as many on this listserv have experienced -, and one of the things I hope all the 4th year students who take my rotation walk away with is how diagnoses are encased in probability - not certainty. I would say most ED diagnosis in particular would be better explicitly framed as "diagnostic hypothesis" that should still be viewed critically and challenged (in a constructive and congenial manner).
> I am sure the extrinsic factors are numerous but ones that come to mind is our billing and coding system. It really doesn't allow for the expression of conditional or uncertain diagnoses. I really wish I could admit someone with the "Not yet diagnosed" qualifier that Pat revealed is available in Canada. Here, I am hand-cuffed by attaching a diagnostic label to a patient encounter even when I am not sure of it. I try to explain the tentativeness of the diagnosis in my charting but that doesn't always get perpetuated in the record. I used to try to get around this by having the patient's diagnosis be their symptom (e.g., shortness of breath, chest pain, etc...) but this is frowned upon.  I think our reimbursement system poses conflict with patient safety goals.
> Perhaps away to address this conflict is to develop a parallel system that assigns a level of certainty to a diagnosis. When practice guidelines come out, the specific recommendations are qualified with some scale that reflects the strength of recommendation and quality of evidence. Maybe our classification system for diagnosis would benefit from similar modifiers that reflect the level of certainty involved... say for example: pulmonary embolism (confirmed vs suspected vs needs further testing).  Just some thoughts off the top of my mind...
> Thanks,
> David
> David Gordon, MD
> Associate Professor
> Undergraduate Education Director
> Division of Emergency Medicine
> Duke University
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