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

Kuhn, Gloria gkuhn at MED.WAYNE.EDU
Sun Jan 12 14:28:05 UTC 2014

This discussion by David Gordon and others  is both valuable and frustrating.
When I began to practice medicine we did exactly what David Gordon suggested:  we used the concept of a "rule/out" diagnosis.  We also had the luxury of putting in the differential diagnosis. Working in the emergency department we often did not have the complete information that would allow us to be "certain" as to what was wrong with a patient.  And even better, if we knew a patient warranted a hospitalization but the diagnosis was not yet certain I could call an attending physician (who often knew the patient from previous care), tell him/her what I had found, admit that I did not know the diagnosis and the patient was admitted.  That was true if the patient did not have a doctor and was assigned to the on call doctor.   Or I could keep the patient and observe until the private physician/on call doctor came to see the patient.

All of that is gone.  Third party insurance companies and the government want certainty.  You can't put down a rule out or you won't get pain.  HMOs and other insurers destroyed the patient doctor relationship forcing patients to choose doctors depending on their insurance companies and insurance companies will often change providers on patients.  That means doctors don't have a long standing relationship with patients and really get to know them

And finally, there is the "rush to judgement and treatment".  In our system an emergency department patient who is not admitted is supposed to be seen and discharged within 150 min. For the simple sprained ankle or cold that works great.  But what about the patient who "doesn't feel good" or feels "weak"?

Admitted patients are supposed to be out of the ED and admitted in 2 hrs (that means a really rapid work up, treatment, and all information back with notification of inpatient personnel).   Once again, great for obvious diagnoses  but what about a complex patient?

Then to make things even more frustrating we have "time dependent medicine".  Pneumonia: diagnose and get antibiotics on board within 4 hours which sounds simple until you realize that not all patients come in with a cough and fever; some come in confused or septic.  Or what about the patient who has abdominal pain and vomiting and turns out to have a heart attack?  Well you are supposed, ideally, to have gotten an EKG within 10 min and gotten the person treated rapidly.  Well, should I order a tropinin on all middle aged patients with abdominal pain and also do an EKG but still choose wisely to save money?.

All of this makes us prone to errors.  Medicine is very complex.  Turning medical care into big business where you need to choose wisely to save money, practice quickly, and ensure safety is a lot to require.  Oh, and I forgot about finding time to really do a good history and physical exam, explain the possible diagnoses and what needs to be done and answer questions for a patient and family.  This  does and should take time.  What doctors no longer have is time and a long history of knowing their patients.

Please understand, my remarks are not meant to sound like excuses or whining.  Someone asked, don't doctors think about and dictate a differential diagnosis?  Yes we think about it but I don't know that we dictate it any longer.  Time shortages, time rules, insurance companies and the government have all changed how we think.  We are to blame also, as we have simply turned to technology to get answers rather than demanding that we have the time to really talk to and examine patients.  That we have the courage to tell a patient that we don't know what is wrong right now and we need to do tests (not all patients are comfortable with that uncertainty and when I have done exactly that a family member looked at his father and said in front of me, "What do you mean she doesn't know?"

 What I am trying to articulate is the complexity of the practice of medicine, the uncertainty inherent in diagnosing patients and the attempt by administrators and insurance companies to apply rules to ensure efficiency and cost savings.  And perhaps our most important sin:  not having the courage to admit when we don't know.
Gloria Kuhn

From: Vic Nicholls [nichollsvi2 at GMAIL.COM]
Sent: Friday, January 10, 2014 10:43 PM
Subject: Re: [IMPROVEDX] Ideas on improving rates of missed/delayed diagnoses in PCP type visits.

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

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