As the pressure mounts to select a diagnosis so that we can order a test, code and bill our charts, meet patient expectations, provide a diagnosis to follow-up and admitting physicians, and now meet the goals of the IOM, the likelihood of misdiagnosis may be even greater than before. Despite our 48 mentions, it is surprising to me how few times they mentioned EMTALA: zero. In today’s environment of increased ED volumes and cost containment, “do more with less and do it better than you did before” is a recipe for diagnostic disaster.
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ACEP Now: Vol 35 – No 01 – January 2016Doing the right thing on behalf of our patients is the key, not assigning an arbitrary, and often premature, diagnostic label. We are so focused on how well we diagnose, we sometimes lose sight of the fact that diagnoses may not be possible at certain junctures in a patient’s illness; we will never reach diagnostic perfection. Furthermore, the house of medicine has manufactured the concept of diagnosis as opposed to signs, symptoms, and pathology, which are real.
We seek the elusive “diagnosis” because that’s what we have done for as long as we can remember; it’s an expectation we’ve created. I propose we put that concept in the circular file. Based on the clinical circumstances, there are good decisions, bad decisions, acceptable decisions, and unacceptable ones, but frequently, there isn’t just one answer. When a presentation is too complex to “diagnose,” why don’t we concede that fact, defaulting to the way medicine should be delivered in the first place, by us for our patients, with shared decision making? Don’t diagnose; just make a reasonable decision that will lead you to the next diagnostic or therapeutic question where you should make another reasonable choice. When the diagnosis is evident, we’ll declare it.
The IOM’s report highlights many important issues; there is tremendous value in its work. I know my concerns may seem over critical. However, from my perspective, so is its characterization of emergency medicine. We need to be recognized as the safety net of the health care system, often with little control over our environment, and be allowed to deliver care free from the pressure of getting every diagnosis “right.” The IOM report speaks to many of the issues that we have fought for but have gone largely unrecognized for years, maybe even decades. Perhaps the IOM report will raise awareness, resulting in provision of the necessary resources our nation’s emergency departments so desperately need.
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6 Responses to “Opinion: Institute of Medicine Report on Medical Misdiagnoses Overly Critical of Emergency Medicine”
February 7, 2016
Jerry W. Jones, MD FACEP FAAEMWhile I do agree with Dr. Klauer that it appears emergency medicine was unjustifiably singled-out ion this study, I would like to add a few observations over 35 years of practicing emergency medicine.
It is an ideal situation if the ED physician is able to arrive at a diagnosis in an efficient and timely manner. Unfortunately, the human machine is not always willing to cooperate and in many cases a definitive diagnosis simply cannot be achieved in the ED within a reasonable time-frame. The next issue for the ED physician becomes “Do I admit or do I refer?” A physician who has listened to the patient’s story – and I don’t mean asked 6 or 7 preconceived “Yes/No” history template questions that “best fit” (but don’t EXACTLY fit) the patient’s chief complaint – has done a focused physical examination – not just the now-ubiquitous “stethoscope tap” chest exam or “momentary palm touch” abdominal exam, formulated a differential diagnosis that is followed, has ordered appropriate lab and imaging tests based on his/her assessment of the patient, reviewed all tests results and addressed any unexpected results, is going to be much more secure in deciding whether a patient with an undiagnosed condition needs emergency admission or simply follow-up with their own physician or a referral specialist.
However, in the last 15-20 years I have noted a serious and progressive decline in the ability of the average emergency physician to perform a competent history and physical exam. In this day of the EHR, many patients have physical exams recorded that never took place. I recall (I’m semi-retired now) medical students and residents arriving for their emergency department rotations without even a stethoscope. I can’t speak as to whether these same deficiencies apply to other specialties, though I suspect they do. We need to take a closer look at how medical students are being taught and instill in all new physicians and physicians-in-the-making that there is more to medicine than ordering a bunch of tests and then trying to explain away – or in some unfortunate cases – simply ignore the unexpected, for no other reason than it doesn’t fit our preconceived notion of diagnosis and/or disposition.
December 25, 2016
N. Newman, M.D., FACEPI could not agree with you more. Rapid efficiency does not necessarily equate to quality of care. So much of emergency medicine is what I refer to as “knee jerk” or “cookie cutter” medicine. The formulation of an immediate diagnosis(even before the cursory physical exam and history taking) followed by the requisite lab and imaging studies. Although some patients are quickly assessed and a correct diagnosis made, some patients require a bit more time. Many times I have taken a history from a patient with what appears to be a simple complaint only to discover that the complaint is more complicated. Personally, I have discovered that as patients “warm” to me, they open up and the details of their complaint are offered. The pressure I experience at times for being less speedy than my colleagues can be tremendous. Because it affects departmental metrics. Although meticulous in my history-taking, physical exam(I insist that patients be undressed) and ordering only what I need for my focused exam, and add what may become necessary later, there simply is no acknowledgment for that type of responsible practice. Only criticism. Fortunately, my patients do recognize my commitment to them and as a result, I have very minimal patient complaints, even from difficult patients.
Despite the requirement of certain ER groups for its ER physicians to complete compliance courses in diagnoses with the highest likelihood of being misdiagnosed or suggesting CME’s in High Risk Emergency Medicine, it is as if we are going through the motions. Ironically, the nature of EHR’s, compliance heavy hospitals and ER departments make it difficult for one to be a true clinician to avoid these pitfalls in emergency medicine. “You’re damned if you do, you’re damned if you don’t”…..
Simply put, the art of medicine is becoming lost in the interest of rapid efficiency. I sincerely have empathy for the new physicians who have less appreciation of this art through no fault of their own. I made a decision years ago to reprioritize and maintain my skill as a clinician: Patients first, documentation second(protect myself and my license) and speed third. It has held me in good stead resulting in minimal patient complaints and no lawsuits for 21 years. Most importantly, I’m happy, as are my patients.
February 7, 2016
P David Cash MD FACEPUntil the Institute of Medicine publishes the names, location, and causes of death of the 100,000 patients per year it alleges physicians kill, I will continue to view any information that this organization provides as absolute garbage.
February 7, 2016
William FranklinEmergency Medicine has its own language and culture. People who don’t practice emergency medicine think it’s just internal medicine in the ER. They picture us having the same leisures they have in how they manage patients, i.e. linearly managing patients with known diagnoses. They will never learn our culture or language because they don’t necessarily even recognize that there is a difference. Like most people, they don’t go looking for things they don’t know are in existence. As such, we will always be misunderstood, I fear.
I have seen positive changes in the way we are perceived over my 20 years of practice, but there is still a way to go. I explain it as thus: Our job is to manage a community resource, the emergency department. Manage is the key word. Everybody else in medicine has the job of managing the patient’s illness. We do that to the extent possible in the background of managing a community resource, but we are never relieved of our duty to first manage a community resource. We co-manage several patients at a time, providing safety for the downstream docs to do their work with major and unexpected medical conditions identified, treated, or ruled out….and like, 5 minutes ago.
We speak a language that nobody else in medicine speaks. Like anybody in that situation, we often can only shake our heads “yes” and move on.
February 7, 2016
Myles Riner, MDLet’s call a spade a spade: the authors of this IOM report let their own prejudices and suppositions distort and misinterpret the evidence, resulting in a misdiagnosis of the problem of diagnostic errors and its causes and impacts on emergency department patients.
February 10, 2016
Hijinio Carreon DO FACEPI believe your comments are right on point with what we as a specialty need to be more outspoken of. The video that IOM created for laypeople (https://m.youtube.com/watch?v=fStBWT6fa3E), is a mockery to physician insight and perception that we would only favor one diagnosis and do not communicate with our patients throughout their hospitalization. The woman with left upper extremity pain that was apparently anginal in nature, states that her long-term morbidity is associated to the delay in her diagnosis. However, they fail to mention if she may have reported any other symptoms to the emergency physician evaluating her on that given day, that may have led him/her to believe that this could be acid reflux. Further, did her symptoms evolve over those two weeks and manifest into more obvious anginal symptoms? If we admitted every chest pain that would be considered clinically low risk, what are the long-term implications to our healthcare system? If we admitted every patient that stated they have a “high pain tolerance” and know that something is wrong, what do we further due to our growing narcotic epidemic? Yet, we find more ways to burden our specialty in reflecting on delays in diagnosis and pointing fingers for the growing narcotic epidemic.
We have all recently been asked to meet the CMS standards for severe sepsis in all of our patients. However, what about the patients in our respective institution that ultimately do not have sepsis? It may appear they could have an infection but for fear of not meeting regulatory standards, still received the 30 ML per kilo bolus and broad spectrum antibiotics. Maybe the patient even had a lactic acidosis, and an interstitial infiltrate that was could reflect pneumonia. What are the implications and long-term morbidity and mortality associated with these patients, that we now have been asked to ensure we hit all quality metrics within a three hour window (just click the sepsis bundle and everything will be taken care of – but the patient)? Did we not learn from the pneumonia initiative, requiring initiatives such as these have negative implications? However, when a patient is negatively impacted because a physician attempted to use his critical decision-making and determine appropriate line of action, he immediately will be referred back to the CMS standards and the IOM initiative and be asked why.
I thought the best statement I heard made at SMACC was protocolized therapy makes stupid people stupider and smart people stupid. Yes, cognitive errors occur in every specialty and each specialty needs to be accountable. Better communication between physicians and physician sub specialties needs to occur, enhancement of our medical school education etc. We need to stop focusing on certain hospital metrics. We need to allow an illness to manifest and focus on patient care!