A question - the primary complaint

Amy Reinert amy.reinert at GMAIL.COM
Tue Nov 22 19:33:41 UTC 2016


Kimberly,

Thank you for the link to the Rosenthal and Verghese article. They make
excellent points, particularly about the loss of connection between
physicians and patients. I found it intriguing that they stated that EHRs
have not resulted in less face time with the patient.

Although I do think that physicians get too little time with their
patients, right now, I'm less concerned with the quantity of time than the
quality. In 7.5 minutes, a sincere and professional physician can interact
with patients in a way that is both respectful to the patient and likely to
yield either a correct diagnosis or an agreement to investigate further
until the answer is found. In that same time frame, a "bad apple" physician
(for lack of a better term) can misdiagnose the patient and also cause the
patient emotional distress by engaging in behaviors that are rude,
dismissive, and dehumanizing. The classic "it's all in your head" dismissal
is a common complaint among patients. In my research, I deal only with
participants who have confirmed medical diagnoses, and catalogue only the
egregious behavior that results in delayed or misdiagnosis, inappropriate
treatment (i.e. Prescribing the wrong drug, ordering the wrong test, etc.),
or ethically inappropriate or criminal behavior. These issues that occur
during the 1:1 encounter have much more to do with the personality of the
doctor than any systems issue. Misdiagnosis is fed from many sources, but
the problem of inappropriate physician behavior in the patient encounter is
one that seems to get overlooked. I believe it is imperative to acknowledge
and explore this problem if substantial improvements in misdiagnosis are to
be made.

All the best,
Amy

On Tuesday, November 22, 2016, Applegate, Kimberly E <keapple at emory.edu>
wrote:

> Amy,
>
> I will add to the discussion by linking to a perspective piece in NEJM
> this week ‘Meaning and the Nature of Physician’s Work’ by David Rosenthal
> and Abraham Verghese:
>
> http://www.nejm.org/doi/full/10.1056/NEJMp1609055#t=article
>
> From my own highly technological world of imaging, I read it and deeply
> agree that yes, we do need to spend more time with our patients and their
> families, and less time with our computers. But then again, our systems are
> designed perfectly to get the results we get.
>
> Kimberly
>
>
>
> *From:* Art Papier [mailto:apapier at VISUALDX.COM
> <javascript:_e(%7B%7D,'cvml','apapier at VISUALDX.COM');>]
> *Sent:* Tuesday, November 22, 2016 9:36 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> <javascript:_e(%7B%7D,'cvml','IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG');>
> *Subject:* Re: [IMPROVEDX] A question - the primary complaint
>
>
>
> Disclosure: I am the CEO of VisualDx (and a practicing physician).
>
>
>
> Amy,
>
> Certainly the drudgery of electronic health information systems have taxed
> many physicians, interfering in the physician-patient interaction and
> causing stress, burnout and fatigue.   Telemedicine while bringing speed
> and access to people in remote areas, is certainly not as personal as face
> to face.  There are problems with technology, but we must be careful to not
> lump “medical technology” into one homogenous bucket as we seek to
> reestablish a more human physician-patient interaction.  Medical knowledge
> accessed on mobile devices, desktop computers and integrated into the EHR
> is more efficient and more useful than books down the hallway.  Books
> reduced medical knowledge to averaged summaries of classic presentations,
> and are limited by space, difficult uniaxial indexing, out of date, and
> hard to retrieve information.  Databases can catalog the spectrum of
> disease presentation, can be designed to reflect and contextualize
> information to the unique clinical scenario.  Furthermore new relationships
> will be uncovered in clinical medical medicine because of digital
> information.   Hundreds of thousands of physicians use tools like UpToDate,
> VisualDx, Epocrates etc and they all prefer these digital medical
> technologies because they are faster, more comprehensive and more current
> than what we memorized from on paper.  Using the new information tools with
> the patient in the exam room enhances the physician-patient relationship in
> this day and age of patients using WebMD and Wikipedia before they see us.
> A physician saying something like “I don’t know, let me check my
> professional database” to a patient instantly communicates to the patient
> that the physician cares enough to pause and look up information on their
> behalf.    Young physicians, students and residents do not see these
> cognitive tools as destroying the physician-patient relationship, they see
> these tools as essential to practice.  I caution all on the list to
> appreciate how varied are the practice patterns, habits and methods of
> physicians.  Physicians (and NP’s and PA’s) are remarkably heterogeneous.
>  Their attitudes and styles are remarkably diverse.  Many are using medical
> technology to enhance the physician-patient relationship.  Using evidence
> at the point of care is a very positive force in healthcare.
>
> Art Papier MD
>
> CEO of VisualDx
>
>
>
>
>
> *From:* Hess, Dr. Donald [mailto:dhess at SUSQUEHANNAHEALTH.ORG
> <javascript:_e(%7B%7D,'cvml','dhess at SUSQUEHANNAHEALTH.ORG');>]
> *Sent:* Tuesday, November 22, 2016 8:10 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> <javascript:_e(%7B%7D,'cvml','IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG');>
> *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?
>
>
>
> Sincerely,
>
>
>
> Dr. Donald Hess
>
>
>
> *From:* Amy Reinert [mailto:amy.reinert at GMAIL.COM
> <javascript:_e(%7B%7D,'cvml','amy.reinert at GMAIL.COM');>]
> *Sent:* Friday, November 18, 2016 1:24 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> <javascript:_e(%7B%7D,'cvml','IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG');>
> *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.
>
>
>
> Respectfully,
>
> A.D. Ruzicka, Ph.D.
>
>
> On Thursday, November 17, 2016, Tom Benzoni <benzonit at gmail.com
> <javascript:_e(%7B%7D,'cvml','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> 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 <javascript:_e(%7B%7D,'cvml','pgbentonmd at aol.com');>
>
>
>
>
>
> -----Original Message-----
> From: robert bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.
> ORG
> <javascript:_e(%7B%7D,'cvml','0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG');>
> >
> To: IMPROVEDX <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> <javascript:_e(%7B%7D,'cvml','IMPROVEDX 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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