Misdiagnosis---why does it occur?

 

When we go to our doctor’s office we all hope that we get a diagnosis for our symptoms.  We further anticipate the doctor to recommend a plan of treatment that will solve our problem or at the very least improve how we feel.  There are many times that we have to see the doctor more than once to obtain any relief for our problems.

It could be a misdiagnosis.  There are many individuals involved with special skills sets that contribute information to make a diagnosis.

We as the patient are the first point of contact.  With the world-wide-web at our finger tips it is very tempting and convenient to “google” our symptoms and attempt to treat ourselves.  This can lead to a misdiagnosis, inappropriate treatment and perhaps (if the condition is serous) a bad outcome.   If there are symptoms that concern us we seek medical care from our family physician or personal care provider.  At the first appointment with this provider, it is up to us to give him/her a history of our illness/concerns. It is often helpful to bring a list of your problems with as much detail as possible.  It is also helpful to bring a list of the questions to address with the doctor. Many times the doctor is busy and we are nervous.  It is easy to forget to ask something important. Before leaving the office, ask the doctor to wait a minute while you check your list to make sure something important wasn’t missed.  

Many times the next area necessary for the doctor to make an accurate diagnosis is diagnostic testing (blood work, x-rays or imaging).  Often the doctor’s staff will schedule these tests for you.  Again it is up to you, the patient to make sure that the tests requested by the doctor are actually the tests you are receiving.  Leave the doctor’s office with a list of the testing the doctor has recommended.  When it comes time for testing ask the name of the tests you are getting, compare them to your list of recommendations and make sure they are the same.  If not, ask the testing facility staff to call the MD or call yourself to clarify the testing required. 

The test results are sent to the doctor that ordered the testing. If you had x-rays or imaging studies, ask if the doctor will also receive a disc of the test results.  If not ask when the test results will be completed and make plans to pick up a copy of the testing on a disc so that you can go over the actual films with your doctor at the follow-up visit.  Keep a copy of the disc so that you will also have it to take to a second doctor should that become necessary.

 In summary:  three areas in which a patient may contribute to poor outcome or misdiagnosis are: self-diagnosis; not reporting symptoms; failure to complete ordered testing

The next area where medical diagnoses can run afoul is in the area of diagnostics.  They are useful tools, but are not perfect as they involve human error and have innate error margins which create false negatives as well as false positives.  We, as patients must be vigilant in following through on the preparation instructions provided for the testing.  If the test results carry a serious diagnosis it may be prudent to have a second test or a second reading of the test results (remember you have your disc of your films) by a second opinion doctor to make sure that the treatment plan you are about to embark on is appropriate and warranted.

 Laboratory and pathology tests are useful, but not perfect; all diagnostic testing may be altered by human error and all diagnostic testing has a certain innate margin of error.

The next person that is essential in making an accurate diagnosis is your physician.  Often the first physician you visit is your private physician who is usually a family practice physician or an internal medicine specialist.  The evaluation and management examination should include a history of your present illness/concerns, a physical examination and a discussion of the diagnosis and the treatment plan.  Medicine has become very specialized.  In many ways this is a good thing, but can also lead to a misdiagnosis.  Many doctors know only the most common diseases, illnesses and injuries.  After all, these are what they see day in and day out.  If you have an unusual problem or a serious diagnosis involving a particular body part it may be prudent to ask for a referral to a specialist in that area of medicine.  There are many other reasons that your primary care physician may not be the best treating doctor.  Primary care doctors are familiar with the patients and may have a bias with regard to diagnosing particular disease.  The may try to save you money and not order all testing that may be necessary.  Unfortunately, many family doctors are extremely busy and due to their hectic schedule may not have or take the time for an accurate diagnosis.  Added to this time constraint, behavior or mental symptoms are hard to analyze and take the doctor’s time and attention.  There are other physician diagnoses problems that involve the physician him/herself as we all have specific areas of knowledge and biases which lead us to certain decisions.  Medical providers are human, most care and try to do the best they can to enable a full recovery for their patient’s.  As the patient, we must provide them with accurate; concise information; ask questions when we are unsure or don’t understand; follow their instructions; and know when it is time to ask for a second opinion. 

 

CNN's World's Untold Stories: Dementia Village

I cried throughout this video realizing that there is another option for the care of our elderly dementia people, but for the lack of public finance and I think public caring for each other, this option (and others) are not available to our loved ones. 

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Story from the trenches—is utilization review a good thing for healthcare?

 

There is renewed interest in utilization review in workers compensation claims management .  The purpose of utilization review is to provide oversight of professional healthcare decision making.  Utilization review can be viewed as providing reinforcement of the professional decisions rather than to undermine these decisions.  This author does not feel that the goal of utilization review should be to save claims’ cost.  This may be a byproduct of the process, but should never overshadow the ultimate goal of appropriate patient care.

 

UR—negative perspective

Many in the healthcare industry would view utilization review as undermining the autonomy of the healthcare providers as it imposes an external control that may mitigate the individual provider’s healthcare decisions.  The second major objection to utilization review is the amount of time it takes to provide the documentation for medical necessity which increases the cost of the provider’s business.  Those that find this a problem also point to the fact that it takes the clinician away from actual patient care.  Another negative often reported when the discussion centers around utilization review is that the standards and clinical guidelines imposed by the utilization review process fail to take into account those individuals who fall outside the standards either with comorbidities or with special needs.  Most important to this author is the risk of delaying access to care by long delays of the utilization review process.

 

UR—redeeming qualities

If one is to set aside the concerns voiced above, it is possible that the utilization review process may bolster the legitimacy of the medical profession by clinical guidelines and standards of care.

One area that may be influenced positively is that an external review may hold all practitioners accountable for their decision making and thus weed out the incompetent providers (or at least limit the questionable practices).  This oversight may in turn bolster the public’s confidence in medical care. 

 

It’s all what you make it...

The determination of utilization review as a “bad” process or a “good” is dependent upon the utilization review agencies policies and procedures.  There are many aspects of the process that either encourage or discourage appropriate care and positive outcomes.  There are several areas in which a payer can determine what utilization review process is most appropriate for their population and needs.  

·         How much documentation and paper work must a clinician submit for the UR process?

·         What is the willingness of the utilization review entity to adapt review protocols in response to changes in medicine and/or complaints of the treating providers?

·         To what extent does the UR process take into consideration demographic treatment norms?

·         Are non-physicians allowed to deny authorization for medical treatment?

·         To what extent are physician reviews allowed to deviate from the formal protocols or clinical guidelines of the utilization review vendor?

The reader may want to address the questions above (and others) when choosing a utilization review company.  Much of the angst for utilization review can be overcome by a clinically driven, but patient centered utilization review process.