Fwd: [IMPROVEDX] motivations for the right dx

Lenny Hoffman lenhoffman39 at GMAIL.COM
Fri Jan 24 01:24:00 UTC 2014

Subject: Re: [IMPROVEDX] motivations for the right dx
To: Lenny Hoffman <lenhoffman39 at gmail.com>

On Wed, Jan 22, 2014 at 4:45 PM, Lenny Hoffman <lenhoffman39 at gmail.com>wrote:

I am Leonard Hoffman MD and a newcomer to your organization. I am a friend
> and a Board member of Cari Oliver's organizations and was excited being
> invited and attending the meeting in Chicago.
> The conversations have been extremely interesting and quite complex,
> wondering what one can do other than being  cautious,continue reading and
> studying, keeping an open mind and trying not to play God or The Doctor.
> I have had the opportunity of running two separate clinics for Pediatric
> residents at two different medical schools in Houston.The last volunteer
> job was  at University of Texas at Houston.
> Residents also rotated through my office from 3 schools in the area.
> I retell the stories of  my errors in diagnosis and how the patients were
>  affected and feel that these discussions made a difference in their
> training.
> I am confronted with the differential of COPD/Emphysema/Asthma often and
> always am concerned about heart failure which was one of my missed
> diagnoses.
> Rather than order the necessary scans and studies, I refer to a
> pulmonologist and cardiologist who help make the distinction. I  am always
> diligent  and concerned that  I am missing something and do a complete exam
> looking for edema as well a check spirometry and oxygen saturation and
> listen to heart rhythm.
> With a low ejection fraction, it is difficult to tell when they also
> are suffering from  severe asthma.
> I have always enjoyed the fellowship of a good partner who shares my days
> in the office.
> We introduce each other to our patients and review the history and exam
> findings with the patient present.
> We do this for coverage reliability but also to reassure the patient that
> we are together in deciding the course of treatment.
> We both respect each other's experiences and feel that we each benefit
> from our presence together.
> My main error which had a bad outcome was 20 years ago seeing a 10 yo with
> history of asthma and allergic rhinitis , depressed, diabetic and not
> following his blood sugars, a family problem with a jobless father and
> mother who as a teacher was doing her best.
> This young man had no edema, no increase heart rate, no enlarged liver and
> had no signs of wheezing or dyspnea but was withdrawn.
> My diagnosis was allergic rhinitis based on exam of nose and nasal
> eosinophilia . I did not hear reduced breath sounds nor wheezing and his
> Insp/expir ratio was normal.There were no rales.
> He failed to come back for a followup visit but appeared after seeing his
> endocrinologist and family doctor who saw protein in his urine an suspected
> UTI. He was treated for kidney infection.
> He appeared as a walk in 3 weeks later markedly edematous with a major
> gain in weight. I was not in the office so my partner immediately referred
> him to our teaching hospital where he was worked up by the adult
> endocrinologist and cardiologist because of his relationship with the
> endocrinologist.
> He was found to be in heart failure with myocarditis and was considered in
> need of a heart transplant.
> The outcome was horrible They were planning a biopsy, stopped his anti
> coagulants , and he developed atrial fibrillation and threw an embolus to
> the brain.
> I never received a followup but the family blamed me for not picking up on
> the heart failure and the malpractice attorney asked me why I did not order
> a special scan to rule out heart failure on the first visit.
> He did recover but I do not know of his final outcome. I did visit with
> him in the hospital and parents were appreciative of my concern but I had
> only met the mother and son one visit.

> At the hearings, the family did not claim I did anything wrong. They just
> wanted my files examined and their attorney was coming after me because I
> was the largest malpractice carrier.
> I was dropped from the case 3 years later after I demanded another
> attorney.
> So what I learned from this?
> Keep an open mind about all diagnoses.
> This was a traumatic experience.
> Leonard Hoffman MD
> Houston Texas
> On Wed, Jan 22, 2014 at 1:42 PM, Vic Nicholls <nichollsvi2 at gmail.com>wrote:
>> I have heard about the "productivity" issue. Does it help if you all code
>> by the level of complexity? For example, if you have 3
>> older/diabetes/hypertension/obesity consults and a heart/cancer patient,
>> I would think that would require a longer visit. How can you all be
>> expected to get that in without scrimping elsewhere?
>> Does it matter if we the patients tell the bosses thank you for spending
>> a few moments with us?
>> My thinking is that if we can help you all better, you all will help us
>> better.
>> Victoria
>> On 1/22/2014 11:11 AM, Karen Cosby wrote:
>>> I'd like to think most doctors always want to be right for many reasons.
>>>  First, the ability to make the right diagnosis goes to the heart of their
>>> professional skills.  Secondly, doctors need to be confident because they
>>> have to trust their skills in moments when their decisions can impact life
>>> and death.  I don't think most doctors need any more incentive than that!
>>>  However, perhaps more importantly, they need freedom from disincentives.
>>>  Increasingly doctors are pushed by limits on times, and limits of testing.
>>>  I know my productivity is being watched and measured, and my
>>> administration isn't shy to embarrass or punish me for not seeing enough
>>> patient's per hour or ordering too many tests.  Many groups offer bonuses
>>> based on productivity. However, I have never known anyone to be rewarded
>>> for a "good save" or "timely diagnosis" beyond their own personal
>>> satisfaction (which is more than enough!).
>> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair,
>> Society for Improving Diagnosis in Medicine
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