The danger of ignoring your instincts


Category : Medical Rants

Recently we had a patient admitted for a diagnosis that did not really fit his problem representation. The diagnosis was a convenient one, and easily treated. He initially responded to treatment and we discharged him. The diagnosis assumption nagged at me, but I did not push forward with a test that my mind wanted.

A week later he returned (the dreaded readmission), with the same symptoms. The admitting resident expanded the treatment for the same diagnosis.

The next morning on seeing the patient we were even more uncomfortable than on the first admission.

As often happens, this is a story of community acquired pneumonia that was not CAP. We ordered a CT scan that clarified the abnormal Xrays. We reviewed the CXRs and CT with the radiologist. His symptoms never fit CAP. His CXR could have been CAP. Only the CT scan pointed us in the right direction.

I preach expanding the diagnostic evaluation when the problem representation and the illness script do no match. Yet, doing so is often difficult. Our patient’s diagnosis was delayed a week, with continued discomfort for that entire week.

So I am challenging myself. I “knew” that we did not have the right diagnosis, but “I did not pull the trigger”. I am not unusual. I suspect we all suffer from this error.

The second time I had no hesitation. How do I convince myself to honor my instincts in such patients?

I suspect you all have experienced similar situations. This story (and I have withheld some details for patient confidentiality) likely seems rather common to others.

I hope to do better the next time. Part of not doing better is refusing to rationalize what happened, but rather learn from the experience. The patient improved dramatically when we treated the right process.

Comments (2)

A lot of medical descision making is conjectural. This was expanded into the book “How Doctors Think” by Jerome Groopman maybe about 15 years ago. We often get tunnel vision from our impressions.

For diabetics (my specialty) one of the critical elements of history for the consultant is what did the last 5 doctors do and what happened when they did it. You can look smarter than you really are just by knowing what not to do.

Thank you for this post. This is a problem that occurs from time to time, and I believe that the current system in place for admissions is a large part of the problem.

We are asked to diagnose people in the emergency department because we need an “admission diagnosis” so that we can make sure that we meet “admission criteria”. The people in hospital administration who require this have never taken care of patients themselves, and they have no idea what they are talking about.

There is a disconnect between administrative types and doctors, and I do not know how this can be solved in our current system.

Example: Patient presents with AMS and is found to have a massive acid base disorder in the ED. What is the diagnosis? I have no idea! I need to admit the patient to the hospital and run a bunch of tests before I can tell you what the underlying problem is. Is it ethylene glycol poisoning? Is it their renal failure? I don’t know.

The current system puts the cart before the horse in requiring an admission diagnosis. What happens is some random diagnosis is given to the patient so that we can get them into the hospital. Unfortunately, because the system demands that we treat the patient with “quality” care, this diagnosis puts a process in place. Now the patient is run through a bunch of tests relating to the admission diagnosis which may or may not be the actual problem going on with the patient. And at the end the patient is sent home, dazed and confused, without a clear understanding of WTF just happened to them.

Think I am kidding? How about this example: Patient present with shortness of breath and the radiologist in the ER says pulmonary vascular congestion. The BNP is 300. Now the patient is admitted with “congestive heart failure”. Do we know it is CHF? NO! But now, because CHF is a diagnosis which beancounters believe they can treat by protocol alone, the patient is set upon a course in which all of the “quality” measures must be met to make sure that we get paid. The patient does not know what is going on, but all of a sudden they are being put on a low salt diet, being given an ACE inhibitor, and so on. They will (hopefully) get an echocardiogram and then….what happens if the echo is normal? SYSTEM FAILURE

To get back to your post, it is often the system that is running away with the patient when we have a sense that the diagnosis is wrong. And studies have repeatedly shown that pinning a diagnosis to a patient early in the process, which is required by the system, leads to significant bias in the doctor’s treatment process and judgment.

What we need in this country is for the doctors to reclaim their rightful place in the system. All of the quality metrics BS needs to go right out the door.

How do we do this? I am afraid that we are going to have to revert to doctor-run hospitals, with all cash. Let patients deal with their own insurance companies.

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