The "disembodied" tele-diagnostician

Bruno, Michael mbruno at HMC.PSU.EDU
Tue Nov 22 14:45:15 UTC 2016

Hi Donald,

I have that book sitting on my desk – it arrived about 10 days ago but I haven’t had time to start it yet.  It sounds fantastic.  Based on what you’ve quoted I also think I should share it with some of my internist friends.

I had an eye-opening conversation with a same-age internist recently with regard to your comment about doctors becoming “disembodied tele-diagnosticians” having “virtual” patient contact.  She and I were discussing a patient and their CT scan which was detailed and questioning and probing.  She was really trying to understand the reason(s) why there seemed to be a disconnect between what she was seeing on the physical exam and what we were reporting on the CT scan. This should not be remarkable at all except that conversations such as that have become exceedingly rare!  I told her that discussing this case with her reminded me of what my life USED to be like, when we radiologists would talk to doctors, often at length, and when the doctors KNEW their patients histories, and where we could sort of “haggle” about the potential significance of imaging findings vis-à-vis the whole clinical picture.  That almost never happens anymore.

Today’s young docs (our trainees) were brought up in an era of multiple-choice tests and have always had the EMR sitting between them and their patients.  They generally accept results without any critical thought, and extract only the most superficial of information from us in Radiology, or for that matter from their patients’ history/physical findings.  According to my internist friend, they even seem to confabulate physical findings (crackles in the lungs, for example) that they DON’T HEAR because they expect them from having read the radiologist’s CXR report!

Our patients aren’t “disembodied.”  Why are our doctors?

All the best,

[cid:image004.png at 01D112FF.F77F98B0]
Michael A. Bruno, M.S., M.D., F.A.C.R.
Professor of Radiology & Medicine
Vice Chair for Quality & Patient Safety
Chief, Division of Emergency Radiology
Penn State Milton S. Hershey Medical Center
• (717) 531-8703  |  • mbruno at<mailto:mbruno at>  |  6 (717) 531-5737

PS:  Just finished Steven Hatch’s “Snowball in a Blizzard,” regarding uncertainty in medical diagnosis/treatment.  Also highly recommended.


From: Hess, Dr. Donald [mailto:dhess at SUSQUEHANNAHEALTH.ORG]
Sent: Tuesday, November 22, 2016 8:10 AM
Subject: [IMPROVEDX] A question - the primary complaint

Re: 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.

I’ve recently read “The Finest Traditions of My Calling” by Abraham Nussbaum, MD. Here’s a quote: “…modern medicine was born when physicians learned to see like scientists. And I suspect that medicine will advance once more only when physicians change their self-perception again”. He goes on to explore what has happened between patients and physicians over the years, and offers hopeful glimpses into how things might be different.

Physician-patient encounters have gradually, perhaps irrevocably, been altered by medical technology. They have now evolved into virtual transactions mediated by a disembodied tele-diagnostician. I sometimes wonder, what are the core traditions surrounding the physician-patient relationship? Are they worth preserving? In light of what the practice of medicine has become, is it even possible to preserve them?


Dr. Donald Hess


From: Amy Reinert [mailto:amy.reinert at GMAIL.COM]
Sent: Friday, November 18, 2016 1:24 PM
Subject: Re: [IMPROVEDX] A question - the primary complaint

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 society.

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<mailto:benzonit at>> wrote:

...should and do are different ideas.

This would be an ideal area for patient involvement.



On Monday, November 14, 2016, Phillip Benton <0000000697ec7b18-dmarc-request at<javascript:_e(%7B%7D,'cvml','0000000697ec7b18-dmarc-request at');>> 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<mailto:pgbentonmd at>

-----Original Message-----
From: robert bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>>
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.




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