My story isn't Serena Williams' story, but some things sound the same

Edward Winslow edbjwinslow at GMAIL.COM
Tue Aug 21 15:33:13 UTC 2018


I absolutely agree with Jason!!

Including several other things that *might *be responsible for at least
some of the patient's complaints is a potential sibliminal technique to
help avoid "confirmation bias". As long as there is a DD (sometimes by the
younger generation referred to as "Rule Outs" - a topic for another note),
clinicians are encouraged to look beyond their "Initial Impression". I am a
little surprised that Jason is asking for FIVE DD points. I used to insist
on three. It would be of interest to ask members of this board, "How many
DD considerations do you believe is appropriate?"

I, also, do like the suggestion that we include as part of the DD, the
"patient's suspicion". I must point out, though, that when I ask patients
what they think might be the explanation for their complaints, they often,
indignantly, point out that they are there for me to tell them. How to keep
this from getting in the way of the physician-patient relationship is
something that we must be aware of.

Ted

On Tue, Aug 21, 2018 at 4:29 AM, Jason Maude <
jason.maude at isabelhealthcare.com> wrote:

> Agree, it’s baffling in these cases why the clinicians seem so reluctant
> to listen. As one doctor wrote recently in an article, why would you not
> add the patient’s suggestions into your differential?
>
>
>
> My thoughts on this have always been that institutions should require
> clinicians to record their differential in the medical notes.
>
>
>
> We have heard of recently of one that requires a differential to be
> recorded and contain at least 5 diagnoses. I would extend this to add
> another box which records both how the patient described their own symptoms
> (in their own words) and also any diagnoses they were concerned about. When
> these things are recorded early on then behaviour will change.
>
>
>
> Regards
>
> Jason
>
>
>
> Jason Maude
>
> Founder and CEO Isabel Healthcare
> Tel: +44 1428 644886
> Tel: +1 703 879 1890
> www.isabelhealthcare.com
>
>
>
> *From: *HM Epstein <hmepstein at GMAIL.COM>
> *Reply-To: *Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.
> IMPROVEDIAGNOSIS.ORG>, HM Epstein <hmepstein at GMAIL.COM>
> *Date: *Tuesday, 21 August 2018 at 02:07
> *To: *"IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <IMPROVEDX at LIST.
> IMPROVEDIAGNOSIS.ORG>
> *Subject: *[IMPROVEDX] My story isn't Serena Williams' story, but some
> things sound the same
>
>
>
> Excellent personal article from a doctor-turned-patient about implicit
> bias in medical decision-making. What can WE at SIDM suggest to doctors to
> change this common error?
> https://www.kevinmd.com/blog/2018/08/my-story-isnt-serena-
> williams-story-but-some-things-sound-the-same.html
>
> Best,
>
> Helene
>
>
> My story isn’t Serena Williams’ story, but some things sound the same
>
> Diana Cejas, MD <https://www.kevinmd.com/blog/post-author/diana-cejas>
> Conditions <https://www.kevinmd.com/blog/category/conditions> August 16,
> 2018
>
> I’m not much of a tennis fan, but I am a fan of Serena Williams. Who
> wouldn’t be after hearing her story? Her rise to the upper echelon of
> athletics was remarkable, and her longevity is incomparable. All the while,
> she has challenged the sporting world’s notions about who and what an elite
> tennis player is supposed to be. I watched her interviews after this year’s
> Wimbledon finals and was once again in awe.
>
> Less than a year prior to this championship, Ms. Williams delivered a baby
> girl and then suffered from a pulmonary embolism and other complications.
> What stuck with me most about her delivery story was the fact that her
> doctors didn’t seem to take her at her word. Ms. Williams has a history of
> a previous pulmonary embolism and knew the signs, symptoms, and management.
> When she became short of breath, she voiced her concerns about the
> possibility of a pulmonary embolism and asked to be worked up for it.
> However, members of her health care team thought that she was confused and
> tried to calm her down. They didn’t seem to believe her. They acquiesced
> after she kept insisting. What would have happened if she hadn’t kept
> insisting? Why didn’t they believe her the first time she said that
> something was wrong?
>
> I need my doctors to believe me. I am quite sensitive about that, and that
> is because I know what it feels like when they don’t. I found a mass on the
> right side of my neck during my first year of medical school. I remember
> pointing it out to my friends after anatomy lab and all of us agreeing that
> I should have it checked out. I dutifully went to student health where I
> was told that the mass was a lymph node and that I shouldn’t worry about it.
>
> Even then, I knew that didn’t seem right. I went back to student health
> and other doctors again and again as the mass slowly grew. Each time I was
> told it was some kind of lymphadenopathy or a random infection and
> something not worth troubling myself about. I asked for imaging and was
> denied over and over again. By the time I was a second-year resident, the
> walnut-sized mass was hard and fixed in place with three rubbery lymph
> nodes on top of it. I knew. I went to another doctor, and when she started
> to tell me not to worry about it, I had what amounted to a hissy fit. I
> knew myself and my body. I knew something wasn’t right and I wanted imaging.
>
> She ordered a CT to appease me, and I had it done that same day. Within
> two hours, I had my diagnosis: carotid body paraganglioma. It was resected,
> and those three lymph nodes were sent to pathology. That’s when it was
> confirmed to be malignant.
>
> Cancer and the stroke that followed it changed my whole life. It upended
> everything I thought I knew about the doctor-patient relationship. I
> realize that I had a relatively rare cancer and that my outcomes were
> unexpected. I could understand my physicians’ reassurance after our first
> meetings. I was young and otherwise healthy. Nothing was supposed to go
> wrong. What I couldn’t understand is that I kept coming back with the same
> complaint, a growing concern, and a growing mass, and despite that, my
> concerns were continually dismissed. I was a medical student and then a
> doctor myself and still felt like no one took me seriously. I started to
> wonder why.
>
> A growing number of studies are examining the way that physicians respond
> to their patient’s complaints. Too often, it seems that physicians downplay
> their patients’ pain, psychiatric symptoms, trauma and other concerning
> issues. Implicit biases and other psychosocial factors certainly influence
> our interactions with patients. Women, people with disabilities, minorities
> and other members of marginalized communities are particularly vulnerable
> to bias within the medical community.
>
> Unfortunately, these biases lead to poor patient outcomes. We, physicians,
> know that these disparities exist but we seem to be a bit unwilling to
> question ourselves about them. How often have we heard patients complain
> that doctors don’t listen to them? That we don’t take our patients
> seriously? How often are these patients labeled as “difficult,”
> “noncompliant” or “crazy?” How often are those patients women? Black?
> Latino? Gay? How often do those patients look different from us?
>
> My story isn’t Serena Williams’ story, but some things sound the same.
>
> We’re both young black women in positions of privilege who faced a
> catastrophic illness. Despite our respective privileges, we both had to
> fight to get the health care that we needed. Things could have been worse
> for us both, but they could have been a lot better too. I wonder if things
> would have been different if my first doctor had ordered a CT scan. I
> wonder if the tumor would have had the time to spread. I wonder if I would
> have had a stroke. Regardless of how things turned out, I’m glad for the
> lessons that I’ve learned. I know now that listening to my patients and
> making them feel heard is one of the most important things that I can do
> for them.
>
> Sometimes a patient’s complaints seem outlandish and their symptoms
> impossible. But sometimes they’re right. Sometimes just listening to a
> patient can save their life.
>
> *Diana Cejas is a pediatric neurologist.*
>
> *Image credit: Shutterstock.com
> <http://www.shutterstock.com/?cr=00&pl=edit-00>*
>
>
> <https://www.kevinmd.com/blog/2018/08/how-i-met-your-mentor-tips-to-finding-sponsorship-and-mentorship.html>
>
>
> <https://www.kevinmd.com/blog/2018/08/physicians-must-reclaim-the-medical-record.html>
>
>
>
>       [image:
> https://drive.google.com/uc?id=0BzqkjTYl6PKwNUhEU2NyZ2RsNW8&export=download]
>
>
> Website <http://hmepstein.com/> Twitter <https://twitter.com/hmepstein>
>
> LinkedIn <https://www.linkedin.com/in/helenekepstein/>
>
>>
> Facebook <https://www.facebook.com/HeleneEpsteinAuthor>
>
>
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> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
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>
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>
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-- 
*Edward B, J. Winslow, MD, MBA*
Home 847 256-2475; Mobile 847 508-1442
edbjwinslow at gmail.com
winslowmedical.com


*“...the more you know about the past, the better you are prepared for the
future.” *

Theodore Roosevelt, 26th President of United States of America






Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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