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

Vic Nicholls nichollsvi2 at GMAIL.COM
Sun Jan 19 16:17:31 UTC 2014


Understandable. However, researching symptoms and blood work changes in
them seems to work every time so far.

High ferritin (not above 1000 but 2x higher than normal), high iron
saturation (41%, 3-4x higher than normal for me) = iron overload or
hemachromatosis. From reading about those items, I could fit everything
I have into that.

Malnutrition, same thing. Not one doctor has been able to tie in to the
6 criteria listed from the experts. They only have one (weight loss)
which flies in the face of what is known about protein calorie
malnutrition and swollen bellies/edema weight gain. Plus, even with a
low albumin, they'll say it isn't that low. I found medical research
showing 3.9 and 3.5 can give you a patient extremely cachetic.

With excess bleeding, I was given a list of parameters. The hematologist
tested all but the Vitamin K. When the Vitamin K was finally tested, it
was so low it didn't register.

Granted, I have a science and computer based background, but I would
think that doctors would be able to query and find the answers. If
that's incorrect, please let me know.

Victoria


On 1/19/2014 10:56 AM, Georges Bordage wrote:
> UpToDate, MDConsult, etc. are only as good as the quality of the
> questions used to access them!  It was Chuck Friedman who said (2011
> AAMC-RIME Address), "You need to know something, to find out what you
> don’t know."  Simply fishing around is not likely to improve things.
> Cheers.  Georges B.
>
> On 1/18/2014 5:33 PM, Vic Nicholls wrote:
>> That is a very interesting observation.
>>
>> I think it would be easier to point out that are those of us who
>> "googled" medical resources and by using things like UpToDate,
>> MDConsult, etc. found our diagnoses. Maybe that would be helpful when
>> a doctor doesn't know what is going on, as it would give differential
>> diagnoses to work through.
>>
>> I can understand doctors being hesitant to try new drugs or the like
>> (unless the patient was ok with it) but I am not sure how reviewing
>> the literature like many of us do to find our diagnoses is a problem.
>> It seems it would cut down on the rates of missed/delayed diagnoses,
>> the #1 cause of lawsuits. Not only that, faster time to dx and
>> treatment, especially for PCP's, would keep a patient off the
>> "frequent flyer" list and give room to others who need medical care.
>>
>> Maybe someone can explain how what I would think would be a win win
>> situation is not.
>>
>> Victoria
>>
>>
>> On 1/17/2014 10:08 AM, Amy Reinert wrote:
>>> Someone earlier in this thread mentioned the difference between
>>> "special cases" and discussion of general principles.
>>>
>>> Rob's point here about communication, combined with the personal
>>> anecdote, brings an important aspect of research, as well as problem
>>> solving, into focus. Misdiagnosis, on most fronts, appears to
>>> originate in the domain of human experience. There is a lot of great
>>> science and techonology that supports the ability to make accurate
>>> diagnoses, but as we've noted in so many different words, at the end
>>> of the day, the practice of medicine is a human endeavor. When
>>> researchers must reach for anecdotal reports to support theories or
>>> arguments, it is an indicator that there is a significant gap in the
>>> research. There has been a great deal of discussion on another
>>> thread about logic and decision making processes. All well and good,
>>> and important, I think, to improving diagnosis. However, in reading
>>> these postings and reviewing the literature, it has become apparent
>>> to me that there is a need for qualitative research regarding
>>> misdiagnosis-- both from the patient and physician perspectives. I
>>> believe that thoughtful collection of anecdotal reports, combined
>>> with meta analysis of the existing literature, will guide the way to
>>> significant advances in improved diagnostic accuracy.
>>>
>>> Best--
>>> Amy Ruzicka, Ph.D.
>>>
>>> On Thursday, January 16, 2014, Robert Bell <rmsbell200 at yahoo.com
>>> <mailto:rmsbell200 at yahoo.com>> wrote:
>>>
>>>     Mis-diagnosis and delayed diagnoses are common, but so is delayed
>>>     communication of diagnosis, particularly in stressful situations.
>>>
>>>     A relative waited 3 weeks after a mammogram to be told that a
>>>     breast biopsy was negative for cancer.
>>>
>>>     Rob Bell
>>>
>>>     Sent from my iPad
>>>
>>>     On Jan 8, 2014, at 5:49 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:
>>>
>>> ------------------------------------------------------------------------
>>>
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>>
>>
>>
>>
>>
>>
>> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair,
>> Society for Improving Diagnosis in Medicine
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