Fwd: [IMPROVEDX] motivations for the right dx

Karen Cosby kcosby40 at GMAIL.COM
Fri Jan 24 02:41:40 UTC 2014

You highlight a reality that is tough for those outside medicine to
understand:  the actual practice of medicine isn't an exact science.  The
signs and symptoms of many conditions overlap. Who would have made the
diagnosis of heart failure absent any of the typical signs; those who
believe they would have need to justify that conviction based on some
criteria. I also wonder, how do you know that he actually had myocarditis
at the time you saw him?  Perhaps it evolved as a sequelae of another
problem, such as a viral illness.  Why do you think it took 3 weeks for him
to return for reassessment?  While we all suffer from cases where we see
ourselves as failing, I'm not sure we are always correct in bearing the
burden we put on ourselves.  Unfortunately I'm not sure there is a clinical
lesson to learn from all cases, only grief to bear.

On Thu, Jan 23, 2014 at 7:24 PM, Lenny Hoffman <lenhoffman39 at gmail.com>wrote:

> 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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