The stories I could tell.
It's not just patients with a history of mental illness. There seems to be a segment of the healthcare system that has an innate tendency to poo-poo certain patients according to their skin color, the name by which they call god, their age, their personal hygiene, there sex, their political leanings, and on and on. In the vast majority of cases I witnessed or was involved in correcting, there was a significant medical problem that, in many cases, would have lead to serious morbidity or mortality if the 'mistake' had not been caught in time.
Perhaps a compendium of cases illustrating each situation and how to teach our fellow professionals to avoid making this type of diagnostic error would be a good project to pursue.
Mark Gusack, M.D.
MANX Enterprises, Ltd.
Agreed. We need to incorporate this into original training.
However, we already have large numbers of active healthcare workers doing this on a daily basis with immediate harm being done. So, from my perspective, one begins here and then moves back towards the nursing, PA, medical schools focusing on the faculty and finally, the students themselves. Otherwise, what gets taught during school tends to be 'forgotten' under the pressures of externships, internships, and residences as I have witnessed.
Good Afternoon Diane:
Perhaps part of the problem is our own fear regarding psychiatric issues which threaten our very self, versus somatic issues which merely threaten our bodies. We can be more easily detached and 'objective' when talking about a patient's cardiac electrophysiology and how we might 'fix' that whereas, when confronted by a patient with psychiatric problems, it's more difficult. One result is a type of defensive behavior towards our own fears by exhibiting distain towards this type of patient.
The answer is to acknowledge this fear and to begin to build a better way to approach these patients in a warm but more 'objective' manner. One way that I was taught by my father was to focus on the history and physical as if the patient had no prior psychiatric diagnosis and only after assessing the findings, factor in the potential for the psychiatric illness influencing the presentation. Another factor is the longevity and trustworthiness of the clinician-patient relationship. If those who are very familiar with this patient are presented with the potentially somatic disorder, they may be able to discern a difference in affect that indicates this really is a separate issue and not the product of the patient's psychiatric state.
Regardless, of the cause of the bias, it's an ever present threat to patient safety. So, I advocate starting at 'the top' with the clinical staff and work backwards towards those teaching in our healthcare institutions, and finally, getting the message to the students so that, when they go on the wards, they experience an identity of ethical standards that they were taught.
Hope you're having a wonderful MLK day!
To expand on this, as you know there is a lot of literature, and I can certainly testify from personal experience, that when we hear a didactic lecture much of what we have "learned" is forgotten in days. Hence, we believe that longitudinal education in medical decision making and diagnostic error is essential to having a meaningful, sustained impact on trainees.
We introduce this with some case-based presentations in the first year of medical school. When on their neurobiology block, for example, we have a 1 hour discussion of a common neuro patient problem, focusing on diagnosis and reasoning concepts. The entire 3rd year medical school class takes a ~ 4-5 hour online curriculum we have developed in medical decision making and diagnostic error. There is an elective in the 4th year that repeats that curriculum and then expands on it with more in depth experience. About 30-40 students take that elective each year.
Our entire Internal Medicine interns and resident class (~ 200) also takes the curriculum. This has now been extended to about half a dozen other residency training programs within our system. We have then integrated medical decision making into their ongoing clinical experience. For example, we have an extremely popular monthly conference in which an experienced faculty person is given a completely unknown case which uses a thinking out loud format for the clinician to explain their reasoning as they work through the case. We have a faculty member from our group who moderates the discussion, focusing not only on the diagnostic reasoning process but also the medical decision making concepts. We also have a brief "case of the month" (~ 10 min case) that the residents prepare that are distributed via email and Twitter, again highlighting diagnostic reasoning and diagnostic error concepts. About 80-100 or so people are doing these cases each month.
Does this make a difference? It is hard to measure but we have observed some indication that perhaps it does.
William P. Follansbee, MD, FACC, FACP, FASNC
The Master Clinician Professor of Cardiovascular Medicine
Director, The UPMC Clinical Center For Medical Decision Making
Suite A429, UPMC Presbyterian
200 Lothrop Street
Pittsburgh, PA 15213
(1.) how the doctors were intellectually seduced into making the error, and(2.) how to prevent others from being seduced into making the same mistake in the future.
(1.) how the doctors were intellectually seduced into making the error, and
(2.) how to prevent others from being seduced into making the same mistake in the future.
(A.) the patient's complaint of pain, (B.) normal MRI, and(C.) the patient's bipolar diagnosis.
(A.) the patient's complaint of pain,
(B.) normal MRI, and
(C.) the patient's bipolar diagnosis.
- the normal MRI, - the complaint of pain, and- the longstanding diagnosis of bipolar disease.
- the normal MRI,
- the complaint of pain, and
- the longstanding diagnosis of bipolar disease.
The points that have been raised here are very good. I want to add another aspect of the diagnostic reasoning process, and that is the over-reliance on advanced testing especially imaging. If a diagnosis is uncertain or the clinician is somewhat lazy or not diligent, an MRI or CAT scan is ordered and if this is negative then the patient is deemed free of disease. In my experience of review of many charts, I have seen too many situations where a patient presents with a complaint of a certain body area, an imaging study is ordered of that area, and this is relied upon to make the diagnosis. As is well known not all pathology. is evident on these scans. I have talked to radiologists and they have expressed concerns that they have become the definitive diagnostic clinician of the patient. A broad differential and use of a proper History and Physical are basic but still vital in our age of technology.
Helmut Meisl MD FACEP
Absolutely correct, Helmut!
We have seen an exponential growth in imaging volume over the past few years, a continuing trend over decades, as unrealistic over-confidence in the power of imaging for diagnosis has arisen simultaneously with a decline in confidence in diagnostic physical exam skills (and decline in the amount of time allotted to doctors in their clinics to try to ellicit a full history). Some of this is driven by the power and utility of the modality, but some is driven largely by financial and time concerns. Since more and more physicians are employees now, and not allowed to have any control of their appointments and schedules, there is clearly a pressure to offload the diagnosis to the radiology department in order to keep the patient encounter short. Some of the problem is also undoubtely due to loss of good physical exam training in medical schools and residencies, and some of it is simply due to clinician anxiety, ordering a scan "just in case," even though the H&P is directing them toward a different diagnosis. Studies presented at prior SIDM meetings have shown that the act of simply ordering a CT scan decreases clinician anxiety, long before any results are available! This is clearly a real driver of the decision to scan, but is not entirely rational.
We have discussed Bayes' theorum in this forum in the past and have also discussed signal-detection theory in terms of ROC curves for evaluating the effectiveness of any test--very commonly used to assess the utility of radiology studies. I can share more about these topics if anyone is interested, but the point is really that advanced imaging doesn't always yield a definitive, final answer--even when there is no radiologist error involved--it's just another line of imperfect and incomplete evidence to add to the overall diagnostic formulation.
One of my colleagues here at Penn State likes to sarcastically refer to the CT scanner as "the truth machine." There is definitely room for clinicians to be quite a bit more skeptical about its outputs than most are. So many disease states look like other disease states (which is why we rely on Baysean reasoning) and there is the very real issue of false-negatives and false-positives, which commonly occur. As the machines have gotten technically so much better and the pictures are so anatomically beautiful, it lends itself to over-confidence in their diagnostic perfection as well.
As a radiologist I would urge maintaining a healthy skepticism regarding what imaging can do for us diagnostically, and also to keep squarely in mind what it can't do, and remember that diagnostic uncertainties usually remain even after imaging. CT or MRI cannot be relied upon as the sole means of establishing a diagnosis any more than any other diagnostic test can.
I also am a strong advocate of evidence-based utilization guidelines for deciding when to use advanced imaging. Performing a CT or MRI study which is not indicated based on pre-test clinical suspicion is tantamount to using the imaging test for screening an unselected population. On a statistical basis, most positive results in such a scenario are likely to be false positives!
Thank-you Helmut for initiating this conversation.
Michael A. Bruno, M.D., M.S., 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 | 6 (717) 531-5737