the danger for passive patients

Ross Koppel rkoppel at SAS.UPENN.EDU
Wed Jan 27 01:34:54 UTC 2016

     Imagine the levels of resistance/irritation/dismissal for 
non-physician patients.  That said, most of my physicians have not been 
dismissive...although when I asked one about an odd result on a blood 
test, he said: "I can't remember that measure. Go google it." Of course, 
I have about a 60 page CV filled with articles in JAMA, JAMIA, NEJM, 
Health Affairs....etc.  So I may not be the typical non-physician 
patient.  Also, I'm not a woman and I've only had pedestrian illnesses.


Ross Koppel, Ph.D. FACMI Sociology Dept and Sch. of Medicine Senior 
Fellow, LDI, Wharton University of Pennsylvania, Phila, PA 19104-6299 
215 576 8221 C: 215 518 0134
On 1/26/2016 7:04 PM, Bob Latino wrote:
> Thank you Elizabeth for chiming in and giving us some background about 
> your journey.
> I know several physicians who felt the same way as you, until they 
> became patients themselves and experienced errors that nearly killed 
> them or their children.
> It was only then did they see the cracks in the armor of the U.S. 
> healthcare delivery system, from the patient's perspective.
> I look forward to your continued participation  on the forum, and 
> working collectively to improve overall diagnoses.
> Thank You
> Bob
> Sent from my iPhone
> On Jan 26, 2016, at 6:44 PM, Regan, Elizabeth <ReganE at NJHEALTH.ORG 
> <mailto:ReganE at NJHEALTH.ORG>> wrote:
>> 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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