when to reconsider a diagnosis

Peggy Zuckerman peggyzuckerman at GMAIL.COM
Mon Jan 20 23:20:52 UTC 2014

Re Karen's comments about patients going to new providers without alerting
the previous, and showing up in the ED with no images, tests, etc.  I do
believe that patients seeking second opinions when dissatisfied with the
first do so with a great deal of trepidation about this.  They may feel
that they will offend the first doctor, that this might interfere with any
subsequent treatment for them or their family, and that his records,
imaging, etc do NOT belong to the patient, or are untrustworthy.

Part two, re the images and such, patients seem to think that "the doctors"
have access to all that data, and that they can get it quickly and
reliably.  We may know otherwise, but what naive patient does not think
that, especially as of late, where BestBuy and Chicos and such can access
one's entire ordering history, find products in other stores, move the
physical stuff to the patient or retail location quite easily.  Why
wouldn't patients assume that the same is possible in the hospital?

The original diagnosis may not have been correct, or not have been
developed with any input from the patient--interrupted within 18 seconds of
telling his story, say the stats. No wonder we all want a fresh start.  And
perhaps we women, often told in clinical terms we are crazy or menopausal
(same thing), or we who lack the kind of education and facility to navigate
these treacherous waters, are right to pack up our tents quietly at night
and move to a new doctor or ED.   At the base of this is lack of
participation in the diagnosis period, and lack of education about the
system to which we are bound,

Peggy Zuckerman

On Mon, Jan 20, 2014 at 2:51 PM, Karen Cosby <kcosby40 at gmail.com> wrote:

> Why aren't you willing to tell the first physician?  Physicians can't
> learn from the experience, or come to recognize a some conditions unless
> they get feedback.  Most of us want to be correct, and we want feedback if
> we aren't.  A Big problem I see is patients switching doctors whenever they
> don't think the diagnosis is correct, rather than returning to the original
> with new evidence or new information.  I saw a patient this week in the ED
> who had been admitted to 2 different academic teaching hospitals with
> extensive workups who came to the ED because they didn't have a diagnosis
> established. (And they came without copies of any of their tests or
> imaging).  Whenever patients switch doctors, most doctors begin all over
> again with the same point rather than build on prior work-- inevitably
> arriving at the same conclusion.  If we don't know what's been done before,
> we can't make progress beyond what's already been done.  We need to explain
> that diagnosis is an iterative process.  We typically begin to workup what
> is most dangerous, things that need to be ruled out to be safe, and common
> things.  Only after that do we consider unusual causes or less common or
> more chronic conditions.  It's not necessarily wrong to take time to
> establish the diagnosis, especially if it's not emergent or common.  We
> should all be lucky enough to arrive at the correct diagnosis in a single
> visit, as if endowed by some special power.  Instead, we sometimes have to
> plod along hopefully with some thoughtful and considered process.  Part of
> the problem isn't always that doctors don't try or aren't informed; some of
> this is a failure to establish trust and communicate the process necessary
> to make a diagnosis.
> On Mon, Jan 20, 2014 at 3:56 PM, Vic Nicholls <nichollsvi2 at gmail.com>wrote:
>> Dr. Gordon,
>> Quite an excellent point. One question for the MD's: how long before a
>> treatment doesn't work are you willing to consider something else? This was
>> a problem I had. The doctor told me to keep taking these pills, just take
>> more of them. The side effects were an issue. I self referred to a
>> specialist and we got the ball rolling. We fixed one problem and proved
>> that there is another underlying problem (the one I said was the issue all
>> along). I never told the original doctor. I will thru his admin though.
>> After 6-7 months of not improving, I was fed up. How do you all deal with
>> this issue?
>> Victoria
>>  On 1/20/2014 12:54 PM, David Gordon, M.D. wrote:
>>>> Bob,
>>>> This may be different for chronic complaints or symptoms that have
>>>> defied diagnosis despite repeat health care visits. In that scenario, I do
>>>> believe that patients pursuing their own research and forcing physicians to
>>>> consider diagnoses that haven't been considered or reconsider diagnoses
>>>> perhaps too easily dismissed could be important.
>>>> -David
>>>> David Gordon, MD
>>>> Associate Professor
>>>> Undergraduate Education Director
>>>> Division of Emergency Medicine
>>>> Duke University
>> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair,
>> Society for Improving Diagnosis in Medicine
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Peggy Zuckerman

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