The danger of admission diagnoses (ht @medicalaxioms)

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Category : Medical Rants

Now that is a strange title.  How can a diagnostic label cause problems?  Yet our current insurance environment actually causes diagnostic delays and errors.

As I understand it, patients need an admission diagnosis to justify admission to insurance companies.  Often in the hospital “quality assurance” representatives require me to assign a diagnosis so that the insurance company will “approve” the admission.

When I started, we admitted patients because they were sick and we needed to figure out what was causing the illness.  A tweet stimulated this post – one of our favorites (@medicalaxioms) tweeted:

Call from ER resident: “I’m admitting this guy for pneumonia. Only thing missing is infiltrate on CXR. And fever. But he does have a cough.”

Once patients have a label attached, thinking is often stifled.  Cognitive psychologists call this the “anchoring heuristic”.  Too often we take comfort in an assigned diagnosis, and proceed to start treatment without questioning the diagnosis.  We all do that.

But often the admission diagnosis is merely a guess.  Our residents know that I assume all CAP (community acquired pneumonia) admissions have something else.  I personally find this the most dangerous admission diagnosis.  But many admission diagnoses are incorrect, because many diagnoses take time to become clear.

Why do we have to provide an admission label?  Again quoting our tweet master:

I’m just as happy to admit “cough fever SOB looks sick.” Happier, actually.

We, who receive admissions, must avoid premature closure.  Listing symptoms allows us to develop a diagnostic strategy.

If we hope to decrease diagnostic errors, we must emphasize not labeling patients with a diagnosis until we have sufficient certainty.  Now how do we explain that to the insurance companies and the “quality assurance” department?

Comments (7)

Another issue which goes with this is the mistrust we create in patients mind – he/ she is not sure who to trust ( the first doctor in ER, the hospitalist who admitted him, the second hospitalist who rounded on him or the specialist who was asked to see him). I often find myself in a situation where I have to subtly refute the nth number of my colleagues knowing that I will not be right each time; I work with the principle of being wrong less often than being more right.

The insurance people and likewise can never understand this nor do they intend to care for it.

Its absurd. In order to get authorization to see a patient from some companies I have to submit a diagnosis BEFORE I see the patient. The idea that insurance companies have any interest in actually facilitating good medicine has been blatantly disproved by inane requirements like this.

Amidoc:
Smart principle.
The best quarterbacks are not the ones who make the most good throws, they are the ones who make the fewest bad throws. Favre would throw five spectacular passes, get down to the opponent’s 10 yard line and then a ridiculous interception. Rodgers would throw five good passes to the ten and then a sixth good one into the end zone.
By the same token the best doctors are not the ones who are right most often, they are the ones who are wrong least often. A subtle but important distinction.

Amidoc is correct. Patients are left wondering who is right, what is wrong, and why can’t someone take the time to talk with me. I have watched as doctors walk in, make sweeping statements about a quick recovery, and then walk out leaving the patient and their family wondering why their doctor did not think of this treatment.

The reality is often patients have multiple issues and need the slow, no downside approach, she is proposing.

Watching competent adults brought to tears, families torn apart, and patients ignored, all because a doctors ego and bias has lead them to a rash statement is hard to fathom given the fragile state of the situation.

Doctors, think before you speak, consult before you start a plan of treatment and remember always, these are people and families who are in a difficult situation.

Steve Lucas

You have a very good point. Sometimes a patient shows up with a straightforward classic presentation of an illness that makes it easy to check all the boxes, but often the situation is complicated. When the ER resident wants to admit someone without fever or an infiltrate the question is what is the actual problem with incipient pneumonia among the possibilities. The diagnostic process can be arduous, and we must admit that there are lots of times when we can’t actually figure things out. Unfortunately, our system requires a diagnosis and may even require action based on that diagnosis such as starting antimicrobials. Our patients also expect something more than “I am trying to figure it out” as our response to their questions.

The analogy of working a patient up to a mystery novel is apt. Nobody expects the detective to know the culprit in the opening paragraph. As with medicine, the story must unfold and sometimes it takes several chapters before there are enough clues to solve the mystery. It’s much easier to be diagnostically accurate as the fourth doctor on a case than the first, since the story is more developed.

Steve, it is true that sometimes physicians could spend more time or be more sensitive than they are, but I wouldn’t be so quick to automatically attribute that to ego or bias. That physician may have another patient doing poorly, may just have gotten out of a family meeting where there is disagreement and anger about a plan of care, or may just be stressed and fatigued from too heavy a patient load. There’s no “debriefing time” for a doctor. The most horrible thing can happen, such as an unexpected code and death of one of your patients, but you have to immediately carry on to the next problem trying to act as if nothing happened. Doctors are like all people – a few are jerks, a few are saints, and most are average people coping as best they can from day to day, which is far from perfect.

Mt. Doc,

Fair.

I was thinking of the friend who’s father had had a number of strokes, was being moved around by two different medical groups to receive the care he needed, only to have a doctor walk up to his bed while his wife and children were there and announce he would have him up and walking in a couple of days.

My friend then had to try and manage the expectations of his mother and brothers while countering this doctor’s statement. This was his last stop, and the doctors who had been caring for him knew they had done all that could be done.

My wife who has CP went to see a new doctor and upon entering the room was told, before being asked any questions, he was going to “fix” her.

Amidoc goes away for a weekend of needed rest only to find on her return her patients had received test she did not feel were necessary.

My list goes on and on.

There are countless doctors, nurses and others trying to navigate a medical system interested in head counts and profit, and just like in business, it seems the jerks get ahead.

Steve Lucas

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