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.
Overconfidence
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.
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