Tuesday, October 14, 2014

Questions to Ask to Reduce Diagnostic Disasters

Part Three of a Seven-Part series on Medical Care
Humans are incredibly adaptable. You can put us into the most bizarre situations, and we somehow learn to cope; eventually, we even begin to accept an untenable situation as almost normal. Unfortunately, this happens in medicine, too. Arrogance, ego, and hierarchy have become entrenched within the culture of medicine. This has led to what Dr. Peter Pronovost describes as “normalization of deviance.” . . . . To have an impact on the millions of misdiagnoses that occur each year physicians are going to have to overcome some ingrained behaviors.
Although some signs and symptoms are obvious indicators of a particular condition, many others are ambiguous and require sleuthing, intuition, testing, and modern technology to determine a correct diagnosis. . . . Ultimately, the most important component to successful diagnosis will be good communication and collaboration between patients, nurses, and physicians. That requires attentive listening by health professionals. Patients need to be able to tell their stories without being interrupted. Seemingly trivial details may provide the key to unlocking a mystery.
Top 10 Questions to Ask to Reduce Diagnostic Disasters
·         What are my primary concerns and symptoms?
Think about a conversation with your physician as if it were a noisy cell phone conversation with a friend. . . . Your doctor may be preoccupied or just not hearing everything you are saying clearly. . . . . The same thing is essential when you tell your story to your physician. Ask her to “teach back” to you what she heard. That way you will be sure she got all the key points.
·         How confident are you about this diagnosis?
Getting the diagnosis right requires a healthy degree of open-mindedness and the realization that something else might be going on. Encourage your doctor to share his level of uncertainty about your diagnosis.
·         What further tests might be helpful to improve your confidence?
This is a slippery slope. On the one hand, you want an accurate diagnosis. . . . Finding the balance between accuracy, affordability, and safety is critical to any decision to seek additional testing.
·         Will the test(s) you are proposing change the treatment plan in any way?
Most doctors are curious. That’s a good thing. They want to know what is causing your symptoms. But sometimes their curiosity can lead to expensive, invasive tests that hurt and may not change anything about your treatment.
·         Are there any findings or symptoms that don’t fit your diagnosis or that contradict it?
Once a doctor anchors onto a diagnosis, it can be hard for him to dismiss it, even if there is evidence that doesn’t quite fit the pattern.
·         What else could it be?
This is huge! If we had time to ask our doctor only one question, this is probably the Big Kahuna. Always ask this question regardless of how sure your physician is that he has your diagnosis nailed.
·         Can you facilitate a second opinion by providing me my medical records?
This is hard. Really hard! Even though patients have the legal right to review or obtain a copy of their medical records, it takes chutzpah to ask a doctor to provide a copy. Many people fear that they will antagonize their health care provider by requesting this document. Some doctors will be annoyed, but the growing movement toward electronic medical records is encouraging patient access.
·         When should I expect to see my test results?
Will you call with them, or will they come by mail or electronically? Doctors and doctors’ offices can be disorganized, just like the rest of us. They are human, after all. The trouble is that their disorganization can have life-threatening ramifications.
·         What resources can you recommend for me to learn more about my diagnosis?
When a doctor gives you a scary diagnosis, it can be overwhelming. Even something fairly common like diabetes or hypertension can seem overwhelming. When you get home and process the information, you may be tempted to turn to Dr. Google for more insight about your condition. . . . The Web has an amazing amount of helpful information if used skillfully, but people may also end up scaring themselves to death with inaccurate diagnoses. Patients can benefit from this incredible tool if they are selective and consult their doctor for interpretations and recommendations.
·         May I contact you by e-mail if my symptoms change or if I have an important question?
If so, what is your e-mail address? Be prepared for your doctor to say no. Most doctors reserve their e-mail for family, friends, and colleagues. Doctors seem to fear that they will be inundated by long messages and questions from patients that will take up significant amounts of their time. . . . Although there is not a lot of research on e-mail communication in medicine, the doctors’ fears appear to be unfounded.
In the world of Veterans Administration healthcare, the MyHealtheVet online system is intended to help with this aspect of your care and communication with your health care provider. However, having said that at this point it is a relatively new system and not fully mature, so don’t expect too much of it.
According to the web information (https://www.myhealth.va.gov),as a veteran or VA patient, in addition to accessing your records (at an authenticated Premium level) you may:
Use Secure Messaging to communicate online with your VA health care team. You may send messages to request or cancel VA appointments. Use it to ask about lab results or find out about a medication or health issue. Or simply to discuss other general health matters.

Part Four will discuss Mistakes Doctors Make When Prescribing Medications

Top 10 Reasons Doctors Screw Up Diagnoses

Part Two of a Six-Part series on Medical Care
Joe and Teresa Graedon, authors of Top Screwups Doctors Make and How to Avoid Them reflected on the simple fact that doctors are humans with limits:
Doctors have an impossible job. They have to learn way more information than any human is capable of retaining during their medical school education and residency training. Then they have to keep up with the latest developments in research and treatment despite grueling hours seeing patients. They frequently have to wrestle with insurance companies and all sorts of other bureaucratic bottlenecks. Finally, they are under enormous time pressure to see as many patients as possible. We have talked with many doctors who complain about having to practice “assembly line medicine.” It’s no wonder that sometimes doctors make mistakes.
Note: quoted passages are excerpts from Top Screwups Doctors Make and How to Avoid Them.
Because medical school and residency training promote the idea that doctors must come up with the correct diagnosis based on their own memories, physicians are destined to miss many diagnoses.
Lawrence Weed, MD, who has spent a lifetime studying these issues, has said:
The physicians’ unaided minds are incapable of recalling all the necessary knowledge from the literature and processing it with data from the unique patient. An epidemic of errors and waste is occurring as we persist in trying to do the impossible.
Dr. Weed and others who have recognized this problem suggest that physicians need to harness the power of information technology to avoid the high rate of missed or delayed diagnoses.
Mark Twain is reported to have said: “It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so.” Based on an analysis of available data, it is pretty clear that physician overconfidence is a major factor contributing to diagnostic disasters. . . . The problem with overconfidence is that doctors may not take the time or be willing to consider alternative possibilities for a patient’s symptoms. One reason for the epidemic of overconfidence is that doctors rarely get feedback about diagnostic screwups.
Information overload
If you’ve ever had to clear away a stack of magazines you’ve been meaning to get to, but just couldn’t keep up with, you may have an inkling of what your doctor faces. There are thousands of medical journals spewing out the latest research in a never-ending tidal wave. A busy clinician who comes home exhausted cannot possibly read all the medical journals in her area of expertise. Throw in the Journal of the American Medical Association, the New England Journal of Medicine, and several other general medical publications , and there is just no way to keep up. Even if your doctor could read half of the relevant research in his field, remembering it, especially at just the right moment to help with a difficult diagnosis, is impossible.
Going it alone
Asking for help doesn’t come easily to many physicians. To get into medical school you have to be a superb student and very competitive. One doctor described such people as “top guns.” They are smart, bold, and driven. They are not necessarily people who instinctively know how to work well with others. Medical school and residency training don’t usually teach teamwork or ego-free collaborative problem solving. When faced with a diagnostic dilemma, such people are likely to try to solve the puzzle themselves. The trouble with this approach, however, is that if they get in over their heads, the patient may drown.
Tunnel vision
In How Doctors Think, Dr. Jerome Groopman talks about something called anchoring: “a shortcut in thinking where a person doesn’t consider multiple possibilities but quickly and firmly latches on to a single one, sure that he has thrown his anchor down just where he needs to be. You look at your map but your mind plays tricks on you — confirmation bias — because you see only the landmarks you expect to see and neglect those that should tell you that in fact you’re still at sea. Your skewed reading of the map ‘confirms’ your mistaken assumption that you have reached your destination.”
Time pressure
One of the reasons that so many doctors end up jumping to conclusions is a lack of time to stop and think clearly. They’re in a hurry all day long, dashing from one patient to the next. . . . Cutbacks in payments from insurance companies and the federal government have led many clinics and hospitals to encourage physicians to see more patients in less time. Some doctors have called this trend “hamster treadmill medicine ” or “assembly-line medicine.” Is it any wonder that physicians feel compelled to interrupt patients within twelve to twenty seconds after they start talking?
Missing test results
“Ordering and following up on outpatient laboratory and imaging tests consumes large amounts of physician time and is important in the diagnostic process. Diagnostic errors are the most frequent cause of malpractice claims in the United States; testing-related mistakes can lead to serious diagnostic errors. There are many steps in the testing process, which extends from ordering a test to providing appropriate follow-up; an error in any one of these steps can have lethal consequences.” Lawrence P. Casalino, M D, et al., in Archives of internal Medicine, June 22, 2009
Ignoring drug side effects
Just about every drug known to man has the potential to cause some side effects in some people. So how does a doctor who wants to do the best for his patient justify prescribing a medicine that could cause heart attacks, strokes, life-threatening liver failure, or kidney disease, to name just a few drug-induced side effects? . . . . When doctors fail to take patient accounts of side effects seriously, they are not likely to report the problems, either to the Food and Drug Administration or as a case report in the medical literature. As a result, other physicians also have more trouble making a connection.
Follow-up failure
One of the reasons that doctors sometimes don’t realize how frequently their diagnoses miss the mark is that they rarely get feedback on how the story ends. Under normal circumstances, the emergency department doctor won’t hear back from the physicians upstairs in the hospital . The specialist and the primary care physician may communicate, but perhaps not as much as one might hope. The patient with a puzzling constellation of symptoms may get passed from one doctor to another to a third or even a fourth before a diagnosis can be reached. At that point, the patient is generally so relieved to finally understand what is going on that she may not inform all the doctors she saw along this torturous path.
Hurried hand-offs
When patients go from one doctor to another, there is no organized system for hand-offs. This is often true even within the same hospital. Many diagnostic mistakes take place in the emergency department (ER). If you have ever had to go to the emergency room, you know what a bizarre setting it has become. There is almost always a waiting room full of people, and the wait time is interminable. Unless you are bleeding on the floor or having a heart attack or a stroke, you could easily be there for many hours before you are seen. The people who work in the ED are harried and often have to make snap decisions under pressure. In one study of malpractice claims, “approximately half of the missed diagnoses (52 percent ) involved emergency physicians.”

Communication breakdown
Whether during a hand-off or at some other time, communication failures cause problems. When patients don’t get to tell their whole story, important clues are missed. When doctors don’t communicate all relevant details to colleagues, the diagnosis and treatment can go horribly wrong. . . . Patients sometimes complain about having to repeat their whole history and all their symptoms to each health care provider they see, but instead of feeling miffed, they should take advantage of the opportunity.
As one can easily see, the fault can be shared by both the patient and the doctor. We must become a partner in our health care. Don’t assume that the doctor “knows best,” because only you know how you feel and are reacting to the medications you are prescribed.

Part Three will discuss Mistakes Doctors Make When Prescribing Medications.

Wednesday, October 8, 2014

Top 10 Screwups Doctors Make

Part One of a Six-Part series on Medical Care
In times past, we were taught that “Doctor knows best” and “Do what the doctor tells you.” Not being medically trained, we accepted that as conventional wisdom — even more so if the doctor visit was made in a military context where service men and women are taught to obey unquestionably the orders of officers set over them.
Conventional wisdom is, unhappily, often wrong, particularly when it comes to our health. The wise consumer will ask pertinent questions and become a participant in their personal health issues.
Mistakes are most commonly made when complete communication is lacking in a clinical situation.
Joe and Teresa Graedon, authors of Top Screwups Doctors Make and How to Avoid Them reflected on the simple fact that doctors are humans with limits:
Doctors have an impossible job. They have to learn way more information than any human is capable of retaining during their medical school education and residency training. Then they have to keep up with the latest developments in research and treatment despite grueling hours seeing patients. They frequently have to wrestle with insurance companies and all sorts of other bureaucratic bottlenecks. Finally, they are under enormous time pressure to see as many patients as possible. We have talked with many doctors who complain about having to practice “assembly line medicine.” It’s no wonder that sometimes doctors make mistakes.
Note: quoted passages are excerpts from Top Screwups Doctors Make and How to Avoid Them.
If we are to receive the best medical care, we must become collaborating partners with our medical providers to help them help us. Doctors must be like detectives to ferret out the true facts of the situation we present them with.
In the same way detectives must listen carefully and question involved individuals to arrive at the truth of a crime, so a doctor must carefully question his patient to grasp the presenting health problem.
Not listening to patients
Studies repeatedly show that many doctors have a habit of interrupting patients within twelve to twenty seconds of the beginning of an office visit. This frequently means that the patient never gets to tell the whole story. When sidetracked by an interruption, she may not ever get to finish telling the doctor about her chief concerns. Because a proper diagnosis depends so much on the patient’s story, interruptions interfere with the ability to make the right diagnosis and determine the best course of treatment.
One of the primary reasons to visit a physician or go to a hospital is to find out what’s wrong. We assume that all those arduous years of training have prepared doctors to figure out exactly why we are having symptoms . It turns out that misdiagnosis is far more common than most patients ever imagine. . . “an estimated 40,000 to 80,000 US hospital deaths result from misdiagnosis annually.”
Providing too little information
Physicians are placed in an untenable position. On the one hand, they are told to follow the tenets of the Hippocratic [O]ath, which includes the admonition to “do no harm.” On the other hand, every medicine they prescribe has the potential to cause side effects, at least in some people. This double bind often results in doctors’ glossing over possible side effects for fear that mentioning them will bring them on by the power of suggestion. . . . in one study of emergency room doctors , researchers found that “information on diagnosis, expected course of illness, self -care, use of medications, time-specified follow-up, and symptoms that should prompt return to the ER [emergency department] were each discussed less than 65 percent of the time.

Not dealing with side effects
You would think that if patients reported side effects from a medicine, most physicians would respond promptly to try to solve the problem. But at least one study showed that doctors failed to address one out of four patient-reported symptoms.
Undertreating or ignoring the evidence
Doctors have adopted a mantra called “evidence-based medicine.” The idea behind it is to use treatments that have been proved effective. [One doctor] has suggested that far too many patients die because their physicians failed to implement the best treatment for their condition. One of the most obvious examples is a failure to prescribe an inexpensive generic drug called spironolactone (Aldactone) for patients with congestive heart failure (CHF), a common and very dangerous condition in which the heart has trouble pumping blood efficiently. Nearly 6 million Americans suffer from congestive heart failure, and one out of five dies within the first year after diagnosis.
Overreacting or being seduced by numbers
Doctors who don’t understand how to evaluate statistics regarding drug effectiveness may easily fall prey to drug company advertising. These ads often lead them to overestimate benefits and underestimate risks. Many doctors believe that more is better. We [the Graedons] have another phrase for this idea, the “lottle” principle: if a little is good, then a lottle will be better.
Overlooking drug interactions
We have been writing about the dangers of drug interactions for more than thirty-five years. This is truly one of the colossal screwups that doctors make on a regular basis, and it accounts for an astonishing amount of disability and death. . . . Americans take an astonishing number of medications, and not all of them get along. Researchers have found that 81 percent of older adults took prescribed drugs. More than half “used 5 or more prescription medications , over-the-counter medications, or dietary supplements.” A surprising number of people swallow dozens of pills daily. . . . A fascinating study was conducted to test prescribers’ knowledge of potential drug-drug interactions. Questionnaires were mailed to 12,500 physicians, nurse practitioners, and physician assistants. These prescribers were asked to determine the safety of fourteen drug pairings. Of the 950 who responded, fewer than half correctly identified all the unsafe combinations.
Failing to revise the plan
A popular definition of insanity is “doing the same thing over and over again and expecting different results.” We frequently hear from patients who have experienced severe muscle pain and weakness as a side effect of a statin-type cholesterol-lowering drug. The doctor responds by prescribing another statin. Although this occasionally works, more often than not the patient has the same symptoms all over again, only to be prescribed yet a different statin.
Overlooking lab results
In a busy practice, a doctor orders a lot of lab tests for diagnosis or monitoring. Unless she has a well-organized system in place for tracking the results when they come back, important information may fall through the cracks. This is far more common than most people realize. . . . Researchers reviewed medical records of over 5,000 patients in twenty-three different medical practices. The investigators discovered more than 1,800 abnormal test results. Of these, 135 patients had never been told the results of their test. That means 1 out of 14 patients with abnormal results did not hear about them. Practices varied enormously in their failure rates. In some cases, as many as one-quarter of abnormal test results were not communicated to the patient.
In other practices, every worrisome lab finding was relayed to the patient. Not communicating test results to a patient can be life threatening.

Not addressing lifestyle issues
Doctors know that healthy habits could replace a lot of medication . Researchers have proved this beyond a shadow of a doubt. One study from Britain followed almost 5,000 adults for about twenty years. People with poor health habits (smoking , drinking too much, not exercising, and eating badly) were likely to die twelve years earlier on average. Even though physicians frequently tell their patients to lose weight , stop smoking, and exercise more, everyone gets frustrated at the lack of progress. Most doctors don’t know how to help patients change their behavior; teaching those skills is not a priority in medical school.

Part Two will discuss Why doctors screw up diagnoses.