When Doctors Dont Listen Listen and What Patients Can Do About It - PDF document

6/12/2013 When Doctors Don’t Listen Listen … and What Patients Can Do About It Joshua M. Kosowsky, MD, FACEP Vice Chair and Clinical Director Department of Emergency Medicine Brigham & Women ’ s Hospital A true story … 48 years old Smoker, borderline HTN, sedentary In the ED with chest pain Jerry 1

6/12/2013 Does diagnosis matter?  Centuries ‐ old debate over whether diagnosis Centuries old debate over whether diagnosis or treatment is more important  No one questions that the right treatment depends on the correct diagnosis  Most of our quality measures assume that diagnosis is right in the first place diagnosis is right in the first place Misdiagnosis  Incidence of misdiagnosis estimated to be 10% to 20% 1  Among malpractice claims, diagnostic errors are the g p , g most common, most costly and most dangerous  An estimated 500,000 missed diagnostic opportunities occur each year in the U.S. at primary care visits alone 1  Schiff et al 2 found that 28 percent of diagnostic errors reported anonymously by doctors were life ‐ threatening or resulted in death or permanent disability  Leape et al 3 estimated that diagnostic errors account for Leape et al estimated that diagnostic errors account for 40,000 to 80,000 deaths per year 2

6/12/2013 An “ orphan ” issue  Largely unrepresented in the current quality framework  National Quality Strategy focuses almost exclusively on management  In IOM report To Err Is Human , the phrase medication error is used 70 times while diagnostic error occurs twice  Lack of obvious solutions  Wrong ‐ site surgery and wrong ‐ dose medication errors are amenable to systems solutions (time ‐ outs, computerized order entry, etc.)  Diagnostic errors seem intensely personal: the system appears to  Diagnostic errors seem intensely personal: the “ system ” appears to be the physician, and his or her own knowledge, skills, values, and behaviors  General tendency to perceive that diagnostic errors are made by someone else (someone less careful or skillful!) Lack of data  No national or system ‐ wide campaign to collect accurate data on diagnostic error g  Doctors often don't know they've gotten it wrong  Diagnostic errors are a leading cause of malpractice litigation, but the vast majority do not result in legal action  Difficulty understanding and measuring diagnostic errors  Little evidence that decision ‐ support tools actually reduce diagnostic error diagnostic error 3

6/12/2013 Roots of the problem  Growing complexity of medicine  Increasing fragmentation of the health ‐ care system  Increasing fragmentation of the health care system  Relentless time pressures  Excessive reliance on electronic data  Expensive, high ‐ tech tests supplanting traditional hands ‐ on skills of physical diagnosis  Learning by algorithm rather than by time ‐ honored  Learning by algorithm rather than by time ‐ honored apprenticeship model Solutions  Medical education  Interventions to improve physician knowledge and p p y g experience (simulation training, improved feedback)  Improve clinical reasoning and decision ‐ making skills (critical thinking, meta ‐ cognition training)  Change in healthcare delivery systems  Financial incentives for safer, higher ‐ quality diagnosis  Patient ‐ focused interventions f d  Improved communication: 80% (or more) of diagnosis is predicated upon patient history 4

6/12/2013 Something patients can do … 8 Pillars to Better Diagnosis #1. Tell your whole story  Provide narrative, not just a list of symptoms  Use chronology and context  Share your impressions  Express your concerns  Practice makes perfect Practice makes perfect 5

6/12/2013 #2. Participate in your diagnosis  Think of diagnosis as a journey rather than a destination  Ask what your doctor is thinking  Understand the concepts of “ differential diagnosis ” and “ working diagnosis ” #3. Understand what tests are for  Every test should be done for a specific reason  Every test has potential harms  Ask:  What are we looking for?  How will the results change things? How will the results change things?  What are the alternatives? 6

6/12/2013 #4. Get answers before you leave  Come prepared with questions:  What is my diagnosis?  What can I expect?  What can I do to get better?  What are some warning signs to watch for? g g  If something doesn’t seem right, ask! Back to Jerry … Reassured about chest pain Understands his cardiac risk Motivated to improve his health 7

6/12/2013 Conclusions  Avoiding misdiagnosis is critical to quality Avoiding misdiagnosis is critical to quality outcomes  Doctors cannot rely exclusively on technology or algorithmic reasoning  Patients can and should be encouraged to take an active role in the diagnostic process References 1. Saber Tehrani AS, et al.. 25 ‐ Year summary of US malpractice , 5 y p claims for diagnostic errors 1986 ‐ 2010: an analysis from the National Practitioner Data Bank. BMJ Qual Saf. 2013 Apr 22 2. Schiff GD, et al. Diagnostic error in medicine; analysis of 583 physician ‐ reported errors. Arch Intern Med. 2009;169(20):1881. 3. Leape L, Berwick D, Bates D. Counting deaths from medical errors [letter reply]. JAMA . 2002;288:2405 8

6/12/2013 Questions? Joshua M. Kosowsky, MD, Department of Emergency Medicine Brigham & Women’s Hospital jmkosowsky@partners.org www.whendoctorsdontlisten.com 9