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.
Misdiagnosing
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.

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