The current issue of Pharos (the Alpha Omega Alpha publication) contains a wonderful article the decries the reflex use of the term CAP (community acquired pneumonia). This article resonates with my experiences. You can download the article in pdf form – Click on selections from the Spring Pharos.
The article tells the story of delayed diagnosis, because the patient had the non-specific label "CAP". A careful history made clear that the patient did not have this non-specific diagnosis.
The problems in this patient's diagnosis remind me of many patients that I see. We label patients too quickly and treat based on those labels. But as one of my favorite commenters reminded me this week, too often we fail to think.
Of course thinking does not lead to payment. We get no credit for careful thought. Actually that is not true, we do not get any external reward for careful thought. But as Daniel Pink reminds us in his excellent book Drive, the best motivators should be our internal motivation rather than external motivation.
When I see patients in the hospital (this paragraph was just as true when I did outpatient medicine), my first goal is to understand what is wrong with the patient. We must first rely on a careful and appropriately thorough history. At a wedding party last night, I had a wonderful conversation with another physician. He recalled being a student when Tinsley Harrison still roamed the wards at UAB. Dr. Harrison always stressed a careful history, and stated that the physical exam should help confirm (or refute) hypotheses that the history presents. If he lived in our days of too many diagnostic tests and imaging studies, he would likely reprimand his students and residents to first take a careful history.
We have no external performance measure for good history taking. We therefore have no financial external reward structure. But I insist that we must value the internal reward of a job well done.
Please read this article – Community-acquired pneumonia: The tyranny of a term
I agree; The misuse of world pneumonia is so common patients look curiously when I ask them about symptoms once they throw the pneumonia word. Other common ones are – are "walking pneumonia"; and "early pneumonia". Very commonly, patients who come with heart failure exacerbation get diagnosed wrongly with pneumonia just on the basis of the CxR as no one takes a history. The 4 hr antibiotic rule in ED is a disincentive to diagnose other disease processes.
Another disease which is classically mislabeled is asthma ("a touch of asthma"). I will be interested in knowing other commonly used mislabels in other fields and why do we, as physicians, give in easily to mislabels?
[…] For the same reasons that I oppose P4P for physicians, I urge the checklist devotees to understand the conditions that make checklists valuable. Checklists help us perform well in routine situations. The likely will not help us with complex decision making. They may encourage mistakes, similar to the problem I ranted about 2 weeks ago – The danger of diagnostic labels […]