the danger for passive patients

Regan, Elizabeth ReganE at NJHEALTH.ORG
Tue Jan 26 21:54:51 UTC 2016


Hi All,
I am a new member of the forum and have been reading the various threads with interest.  I am very interested in learning how to effectively participate in improving diagnosis and patient care.

I had a set of beliefs for many years that patients needed to be their own advocates and ask questions of their doctors.  I often advised my patients that they should do this when they told me about problems that they had encountered. I believed that they were likely to get a fair hearing and careful, thoughtful responses from their doctors.

I further believed that possibly the patients didn't understand or recognize problems or were too reticent to ask clear questions.

I have had some personal experiences in recent years that have caused me to re-think those beliefs.
As a physician I have found that when I ask questions of doctors that are my physicians I often get badly inadequate or simply wrong answers.  Sometimes dangerously wrong.  Incorrect interpretations of testing results with an emphasis on dismissing a diagnosis when the test is not adequate to derive that opinion is a very common result.  For quite a while I was privately embarrassed for the physicians involved and did not say anything.

However, due to changing situations, the wrong answers have in some situations become significant enough that failing to speak up and push back - left me with real problems.  So what I learned is what my patients may have been trying to tell me years ago.  It is often not safe to challenge the physician.  I have repeatedly seen physicians become angry and retaliatory when questioned or challenged.  I want to believe that we are all committed to seeking the best for our patients, striving to find the right answer, committed to honest communication.  Unfortunately physicians are human and some may not share those ideals.  I think the trends to make physicians just cogs in the wheel of "health care" may be aggravating the problem of diagnostic error because there is less of a sense of mission, commitment and idealism in being a cog.

There is also a perverse incentive in diagnosing disease.  The old book,  House of God identified it.  If you don't take a temperature/ do an EKG, CXR or whatever, you don't have to diagnose the fever, the MI, the pneumonia.  If you don't diagnose a problem you don't have to treat it and your work load is reduced.  I'm sure we have all been there, where the last patient of the day has a significant problem and you know that you won't be getting home for dinner because it is going to take a couple of hours to figure out the details for that situation.

I can't readily catch up on all the discussions that have happened in the past in this forum but I'm anxious to learn and participate.  My first thought is that physicians often lack a good education in epidemiology and for example, as a result do not know how to interpret test results properly.  There are very few tests that give you a Yes No answer in medicine.  Most tests have been evaluated in populations and there is a mean and standard deviation for both the healthy and sick population.  If a patient is symptomatic that may affect how the test should be interpreted due to the impact of Bayes theorem and the disease prevalence.

I have heard many physicians in recent years state emphatically to myself or others that "I have no worries/concerns about this diagnosis for you based on that test."  Unfortunately  - that test is not that reliable enough to make those kinds of statements.    I agree that pathologists and medical technologists can be very important to provide guides and information with the test results, but there may need to be changes in how we initially teach and continue to teach medicine.  Hedging, telling the patient you are concerned but for now things look OK, repeating tests in a certain period of time, are tried and true ways to convey caring and caution.  I don't understand why there is so much energy devoted to rigid and potentially wrong interpretations.

Finally I think that we need to collect data on medical errors in the same way that there has been data collected on screening activity.  There could be sentinel diagnoses in every specialty that are tracked for bad outcomes and death.  As we move to narrow networks and patients are stuck with a small group of physicians, there needs to be more effort to show that those networks are not harming patients.

Liz


Elizabeth A. Regan MD, PhD
Associate Professor
National Jewish Health
1400 Jackson St, K706
Denver, CO 80209

303-398-1531


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