Fwd: [IMPROVEDX] motivations for the right dx

Victoria Nicholls nichollsvi2 at GMAIL.COM
Fri Jan 24 14:07:52 UTC 2014


Karen

You raise an important point. I think there is a case to be made where
a number of doctors I've had would wait and wait and wait on a
diagnosis. In light of the symptoms still occuring, getting worse,
they still stuck with the original diagnoses. There is a line drawn
between waiting and having your patient deteriorate on you and nothing
gets done. If the same old treatment isn't working, re-evaluate.

I think patients can handle that. Most I know can. Its when this is
NOT the case that people get perturbed.

I have an issue right now where a doctor that I think is good made a
mistake. Either a test wasn't ordered or didn't come back. I think it
was missed. Well ok, lets just do the test is my attitude. The problem
is that *I* don't get that attitude back from doctors. Multiple ones
all take it as a personal affront if you say something like, 'didn't
see the results of this, can we get it run', and want to drop my care
because *THEY* made a mistake.

The attitude is worse on the professional than the patient side. Now
if people get this attitude from both the professional AND their
adminstration when someone makes a mistake, what does this say about
the profession?

Victoria

On Thu, Jan 23, 2014 at 9:41 PM, Karen Cosby <kcosby40 at gmail.com> wrote:
> 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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>>>
>>>
>>
>>
>>
>>
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>> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society
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>>
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>
>
>
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> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society
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>
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