A question - the primary complaint

K D kvdavis at COX.NET
Thu Nov 23 01:02:08 UTC 2017


Interesting... as Arizona is ranked 2nd worst state to practice medicine in...

https://www.medscape.com/slideshow/best-places-to-practice-2017-6008688#29

The times I have contacted my state board (including the state nursing board, whose "oversight" of nurse practitioners appears beyond their capacity), I was informed the board does not have the capacity or manpower to follow up...

The reality of practicing medicine in the US now is wholly dependent upon bureaucratic baggage from both government and for profit entities who have patient care at the bottom of their priority lists.

If you're not cynical, you are not paying attention.

> On November 22, 2017 at 1:56 PM Michael Grossman <Michael.Grossman at MIHS.ORG> wrote:
>
>
> Dr Benzoni, your message is probably true in many states. In Arizona physicians are instructed to notify the state licensing board if there is overt suspicion of inadequate medical care being provided by another licensed physician. This allows the board to do a confidential review of said physician all done anonymously . You receive a message from the board and a thank you. But no revelation of their findings. This also applies to observed errant behavior.
> In my experience this has worked well
> More states should institute this.
>
> Michael Grossman, MD,MACP
> Professor emeritus university of Arizona College of Medicine
>
> > > Sent with Good (www.good.com)
>
>
> -----Original Message-----
> From: Tom Benzoni [mailto:benzonit at GMAIL.COM]
> Sent: Tuesday, November 22, 2016 01:51 PM US Mountain Standard Time
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] A question - the primary complaint
>
> Ms. Zuckerman:
>
>
> We in practice do indeed know who are the incompetent physicians among us.
>
> And you (plural, society) have decided that we are not to say anything.
>
>
> You see, to speak up is to risk losing all in a court of law, which expresses the will of the people.
>
> There is no protection for whistle-blowers.
>
>
> So until this is fixed, incompetent practitioners will continue to be big profit centers.
>
> (You can generate a lot more bills off a botched procedure than an expertly done one.)
>
>
> Cynical? I don't think so. I think it exposes the system operating as designed.
>
> "Every system is precisely designed to achieve exactly the results it gets." (Berwick) (as nearly as memory can pull out)
>
>
> tom benzoni
>
>
> On Tue, Nov 22, 2016 at 2:06 PM, Peggy Zuckerman <peggyzuckerman at gmail.com> wrote:
>
>
> As a patient who was misdiagnosed with a non-existent stomach ulcer, despite a pathology report countering the diagnosis, and later found to have a large and metastatic kidney cancer, I am likely biased in my response.
>
> I feel that until patients are empowered to have immediate access to all their data as soon as it is produced, there will not be real improvement as to diagnostic errors. The unprofessional actions of the doctors or the cognitive errors can be counter-balanced by the engagement of the patient in the process. As a minimum, we patients will not be mistaken for our sisters-in-law with the same name, or be given a medication to which we are allergic, and we will be able to provide relevant tests from an earlier appointment and clarify the medications we are taking compared to those which have been prescribed to us.
>
> Of course, we also have the right to assume--wishing it were the case--that the unprofessional and just plain incompetent doctors will be outed by the good guys. Still waiting.
>
> Peggy
>
>
> Peggy Zuckerman
> www.peggyRCC.com
>
>
> On Tue, Nov 22, 2016 at 8:40 AM, Amy Reinert <amy.reinert at gmail.com> wrote:
>
>
> Art,
> Thank you for your response, and your excellent points about medical technology. I do agree with them.
>
> Perhaps my point was not clear enough. If the physician is one of those who maintains a consistently suspicious, rather than interested, view of patients; if she is one who brushes off complex cases by telling the patient "it's all in your head," won't look past his initial bias, or is otherwise disinclined to be professional, then none of the great tools made available to physicians will help. In order for these wonderful tools to provide the support that they can offer, the physician must first use the tool. This is part of the problem-- physicians who brush off patients for whatever reason, never taking the time to run proper tests or do a proper exam. These are not the ones who will use technology to aid in answering patient questions.
>
> I would bet that most physicians are willing to use the tools some of the time. Unfortunately, what I am learning through my preliminary research is that there seems to be a large enough population of physicians who do not behave professionally with all of their patients all the time that it seems we need to acknowledge that egregious or careless physician behavior exists, and it is important to consider the degree to which it affects misdiagnosis. It is difficult to measure what goes on during the one-one encounter in the exam room, so it is difficult to measure just how large a problem it is. I suspect that it is quite large, though, due to the volume of patient reports of rude, dismissive, aggressive, and in a few cases, criminal behavior that takes place in the exam room. Unfortunately, the doctors write the notes, so they make the only official record of the visit. That presents a problem of power dynamics. So, as I stated in my first message, I have been working on a research design to quantify the problem so that it can be addressed.
>
> I do believe that most physicians are sincere in their desire to be healers, and do their best in systems that do not support them. However, physicians are human, and some behave badly toward their patients, or at least some of their patients. Some of these probably know that they are doing this, but I suspect many don't. So, in the interest of taking action to improve diagnosis, I believe this is one issue that needs to be explored and better understood so that it can be resolved. The physician-patient encounter is the foundation of diagnosis.
>
> I welcome continuing dialogue on this issue.
>
> All the best,
> Amy
>
> A.D. Ruzicka, Ph.D.
>
>
>
>
> On Tuesday, November 22, 2016, Art Papier <apapier at visualdx.com> wrote:
>
>
> 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 toolsh 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]
> Sent: Tuesday, November 22, 2016 8:10 AM
> To: 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, perhtered 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]
> Sent: Friday, November 18, 2016 1:24 PM
> To: 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> 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
>
>
>
>
>
> -----Original Message-----
> From: robert bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>
> To: IMPROVEDX <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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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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