A question - the primary complaint

Amy Reinert amy.reinert at GMAIL.COM
Fri Nov 18 18:23:52 UTC 2016

In my encounters with misdiagnosed patients, or patients with rare
disease or complex problems currently in the (rather exhausting) diagnostic
process, this focus on only being able to discuss one problem is a source
of patient frustration.  Regardless of the physician's reason for stating
this limit, patients report feeling dismissed, angry, patronized,
disrespected, or disbelieved. Being educated toward some degree of
expertise in human behavior, I conclude that it is not the "one symptom
focus" that leaves the patients so upset, but rather the way the message is
delivered. Simple demeanor in communication. Human beings are not data sets
with neat flow charts, nor does each one present in the physician's
preferred manner. This is no excuse for not taking the time to listen,
using appropriate training to read between the lines, ask follow up
questions, and treat the patient with respect. It takes just as much time
to behave in this way as it does to behave in a rude, dismissive, or
sometimes even aggressive manner. If physicians feel powerless within the
various systems influencing medicine, surely the patient encounter is not
the place to compensate for that sense of powerlessness by becoming a
bully, yet too often, in my research, this seems to be the case. It is a
problem that appears to be common knowledge to all but the physicians
themselves. Perhaps gallows humor, professional courtesy, or empathy
fatigue prevents physicians from identifying others within their ranks that
behave inappropriately, or even incompetently, in the one-to-one
physician/patient encounter. Based on my research with patients, it is a
problem that needs to be addressed. I am currently trying to design a study
that will quantify this problem, including the cost associated with repeat
visits necessary for correct diagnosis, as well as the social and economic
ramifications of leaving persons lingering unnecessarily with advancing
disease. Medicine is part of the larger web of society, and it cannot be
ignored that what happens in the patient encounter has ripple effects far
beyond the individual patient, doctor, or hospital. Still, as a field,
medicine seems reluctant to welcome the contributions of relevant expertise
from other fields that may help resolve some of its issues. If any of you
get ahead of me in carrying out such a study, Godspeed. It must be done.

I have watched discussions in this group for some time with great interest.
I've noted the discussions of EHRs, lab problems, diagnostic software,
medical education, charts and graphs, etc., with great interest. I've also
noticed that the closest the group has come to discussing egregious
physician behavior is within the exchanges about cognitive bias that
occurred some time ago. I suggest here that it is a much larger issue than
might be seen from inside the ranks. Until medicine is willing to integrate
awareness of power dynamics, the limits of physician training and
consequent limits on appropriate medical conclusions, and social justice
into its collective consciousness, I believe that misdiagnosis will
continue to be a very expensive and frustrating problem for the rest of

Perhaps this statement might come across as unsympathetic to the physician.
Perhaps it is. This does not mean that I am not sympathetic the plight of
physicians in general. I do respect the demanding work, the fatigue, the
problems inflicted by profit focused administrative systems, and abusive
patients. Unfortunately, the entire field boils down to the needs of the
patient. Without sick patients, there would be no need for physicians.
Therefore, regardless of what changes might be made in software, systems,
education, etc., very little progress will be made in diagnostic accuracy
until improvements in individual physician-patient encounters are made.

A.D. Ruzicka, Ph.D.

On Thursday, November 17, 2016, Tom Benzoni <benzonit at gmail.com> wrote:

> ...should and do are different ideas.
> This would be an ideal area for patient involvement.
> Tom
> On Monday, November 14, 2016, Phillip Benton <0000000697ec7b18-dmarc-
> request at list.improvediagnosis.org
> <javascript:_e(%7B%7D,'cvml','0000000697ec7b18-dmarc-request at list.improvediagnosis.org');>>
> wrote:
>> We have to have data from that encounter and then outcomes data to know.
>> As for the encounter, EHR should give you all the PHx and FHx without your
>> having to ask again.
>> Phillip Benton
>> pgbentonmd at aol.com
>> -----Original Message-----
>> From: robert bell <0000000296e45ec4-dmarc-reques
>> Sent: Mon, Nov 14, 2016 8:45 pm
>> Subject: [IMPROVEDX] A question - the primary complaint
>> I have noticed that physicians when seeing a patient in an office setting
>> often focus on the primary complaint with laser like enthusiasm, almost to
>> the exclusion of anything else.
>> I suspect this is mainly related to time restraints.
>> However, in the big scheme of things is the past history, family history,
>> drug allergies, etc. etc. that important?
>> In terms of a wrong diagnosis, or bad outcome, is this a small,
>> intermediate or large problem in the number of diagnostic errors made?
>> Rob Bell M.D., Ph.C.
>> Moderator: David Meyers, Board Member, Society to Improve Diagnosis in
>> Medicine
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