The Empowered Patient

Today, CNN.com is featuring an article called "Five commonly misdiagnosed diseases" on their editorial "The Empowered Patient" by Elizabeth Cohen. The article begins with a large picture of John Ritter, mentioning that he died of an aortic dissection; his family later won a malpractice suit alleging that he was misdiagnosed "at least twice." She alleges that "certain diseases are misdiagnosed over and over again. It's worth knowing what they are so you won't be a victim."

The five diseases mentioned: aortic dissection, cancer, coronary artery disease, acute MI, and infection. Three of these (cancer, MI, and infection) are from a study at Harvard by Gandhi TK, et al regarding settled malpractice claims in the outpatient setting (Ann Intern Med. 2006;145:488-496.)

The solution, or "how can you keep yourself from becoming a victim of misdiagnosis?" Here are the five ways given to protect yourself: "Ask for more tests", "Ask 'what else could my illness be?'", "Don't assume no news is good news", "Assume your doctors don't talk to one another", and "Be wary when your doctors work in shifts".

I'll just throw this out here now: I greatly dislike this column. There is a little defensiveness on my part, I'll admit it; doctors do make mistakes, every day, but I don't like the tone of some of the articles. However, let's examine her evidence a bit, and I'll see if I can't give you a reason to question this article as well.

Issues I have with this article:

1) John Ritter: His family did indeed sue the hospital (successfully) for "missed diagnosis". Cases against three doctors are still pending until 2008. Even though he was apparently in emergency surgery within 4 hours of arrival at the ED, he died on the table. See Rangel MD's post on why he thinks the ER docs followed all the right steps, and why the "misdiagnoses" were appropriate steps along the pathway to the correct diagnosis. If you really want a blatantly misdiagnosed aortic dissection, look at Jonathan Larson (author of Rent); he was sent home from two ER's with "flu" or "stress" and died suddenly at his apartment.

2) Aortic dissection in general: For a proximal aortic (acute) dissection, 40% die immediately. Within 24 hours, 70% die. If left untreated, the condition is eventually 100% fatal (or close enough). A proximal dissection is a surgical emergency; if treated, there is a 70% 3-year survival rate. Distal dissection is better managed medically, as the surgical mortality is high. Interestingly, "Overall survival rates at ten years are approximately 5% for untreated patients and 50% for treated patients (49). Operative mortality has decreased to about 20% (57)." (Auer J, et al). In other words, 20% of patients still die in surgery, and 50% of the patients still don't make it 10 years even with good treatment. This is a big, bad disease.

Misdiagnosis is only going to make this worse, of course, because delaying surgery in an acute proximal dissection (Stanford A/Debakey I-II) can be fatal. Unfortunately, a chest X-ray has only 67% sensitivity and low specificity, because a wide mediastinum could be caused by many things. The test of choice is CT angiography, which takes a little longer and requires IV contrast, but has a sensitivity/specificity of 96-100% (See Wikipedia article). In this case, one of the things Ritter's widow alleges is a "simple X-ray" would have given the diagnosis; this is not entirely true.

Moral of the story? Misdiagnosing an (acute proximal) aortic dissection is almost certainly a death sentence, especially if treatment is delayed for days. However, if 4 hours was too long for Mr. Ritter, then I'm not sure he could have been saved (and that's my personal opinion--things take a while in the ER, doing the ABC's and getting the EKG and the chest x-ray and the CTA and calling the OR and the cardiothoracic surgeons and getting an unstable patient to surgery, etc. This stuff takes time. I don't know whether this 4 hours is below the available standard of care at that hospital. In other words, I don't know whether this constitutes a breach of care or not.)

3) Coronary artery disease: "Sometimes doctors tell patients they're short of breath because they're out of shape, when it's actually coronary artery disease, says Bonow, who's also the chief of cardiology at Northwestern Medical School." This quote is meaningless because a) If you interviewed a pulmonologist instead of a cardiologist, he'd have told you that shortness of breath could be an undiagnosed PE. Pick your specialist, pick your disease and b) There's no references (besides Dr. Bonow) or studies here, so I can't really say how often this occurs.

Basically, you diagnose CAD by visualization at angiography or after the patient has had acute coronary syndrome (angina, MI, etc.). There's no one great screening test for CAD. We approximate by checking risk factors: family history, smoking, cholesterol profile, blood pressure, and diabetes are the biggest ones (of course, there are others). In a patient who fits the picture, we may offer stress testing or other measures. Sadly, not all patients fit the stereotype, and I'd imagine it's a younger, fit person who presents atypically who would be misdiagnosed more frequently (this is just my guess). Patients with no/few risk factors may still have CAD.

While I do think it's negligent to just tell a patient "you're just out of shape" without doing any kind of exam or workup, I could see how a patient might fall through the cracks here. I couldn't find any studies to say how often CAD was misdiagnosed (and I'm referring to asymptomatic CAD, not acute coronary syndrome).

4) "Demand more tests." The example they gave here, of the RN whose endometrial cancer was misdiagnosed for 3 years as "menopause", is probably the one example in the article where if I were that patient, I might have sued. Then again, if I were that worried, I'd have gone to another doctor. Heavy bleeding in a perimenopausal woman should be ruled out for endometrial carcinoma, period (ha!). I'm not sure the "simple ultrasound" she mentions would have done the job (although it can be used as a screening test by the thickness of the endometrial stripe or by ruling out fibroids) but she warranted an endometrial biopsy. If her doctor didn't at least recommend one, he/she was negligent, IMHO.

However, more testing isn't always going to solve your problem. While failure to order a diagnostic test was the most common reason a diagnosis was missed in the Harvard study (55% of the errors studied), that means 45% of the errors were made even with the appropriate testing. Additionally, errors in the testing itself were also common; just because a test is ordered doesn't mean it will be performed or interpreted correctly.

5) "Be wary when your doctors work in shifts." Up until now, the article has mostly dealt with outpatient issues. The Harvard article (which wasn't actually cited, I had to search by "malpractice claims" in PubMed to find it) deals only with outpatient mistakes. Doctors who work shifts are typically inpatient. The article cited here, "Fumbled Handoffs", is a case study by the same Dr. TK Gandhi from Harvard ( Ann Intern Med. 2005;142:352-8.). The error she attributes to "multiple handoffs", however, actually comes from a human error (a wrongful interpretation of a chest x-ray as "normal", written on the chart) which was given in handoff with the patient. She then describes a "diffusion of responsibility" associated with multiple handoffs, ie the receiving resident should have read the chest x-ray himself. I don't think that's an error of the handoff policy, but rather of the resident believing the night float resident's documentation in the chart. Basically, he should have looked it up himself, whether the person speaking to him was the night radiology resident or the float resident. To me, this error had nothing (or little) to do with the float system.

Through a documented series of MULTIPLE errors, in this case study, an elderly man died of TB after his diagnosis was missed on several occasions. Certainly, medical handoff policies can contribute to errors. Here's an abstract of a policy on how to reduce errors with handoffs.

I think it's misleading to include this information in this particular editorial, because a) other data in the article is outpatient, not inpatient; many people reading the article may not understand this distinction, especially since the 2006 study is not actually referenced properly and b) I disagree with Gandhi's emphasis on the multiple handoffs in this patient's misdiagnosis in the case study. I'm not denying that this type of error can occur, but I think a different study would have served better to illustrate it.

Also, as Gandhi points out, studies have shown that "traditional" medical shifts with overnight call also cause error. Look at Landrigan et al, NEJM 2004;351:1838-1848 for this study of ICU residents working q3 call shifts compared to a reduced schedule of 63 hours/week with no overnight calls; the interns working fewer hours made 35.9% fewer "serious medical errors". My concern is that if we don't clean up the errors in the handoff process, we'll all be working q3 again, which isn't really good for anyone, is it?

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Here's my guide to being an empowered patient:

1) Ask your doctor questions. It's his/her job to answer them, even if they're dumb questions.

2) If you disagree with your doctor, and you can't get an answer you think is reasonable, get a second opinion.

3) If you look stuff up on the internet, use something like WebMD or eMedicine. Do not go to Cletus' Sight on Awtism and the Vaccine Devil!, because *gasp*, you won't get balanced information there.

Doctors DO make mistakes, every single day. They can be serious. Inform yourself and ask tons of questions, and if you think a mistake is being made, speak up.

I Lack Insight

I had a patient on my pediatrics rotation whom I'll never forget.

She came in the middle of the night in DKA. She'd passed out at home and been brought in by EMS with her worried mother in tow. Fifteen years old, she was disheveled, wearing huge sweatpants and a baggy t-shirt.

The intern said I could do the H&P interview, so we politely asked her mother if we could speak to her daughter alone, the mother left, and we sat down to talk to the girl.

At first, the interview was fairly normal. How long have you felt bad? Have you been taking your insulin? Have you been sick recently? How long have you had diabetes? When was the last time you saw your pediatrician?

She told us she'd recently moved, that she was under a lot of stress from switching schools, that she'd maybe forgotten her insulin once or twice, and she'd been a little tired lately.

In adolescent interviews, there is a series of questions for the "sex, drugs, and rock & roll" topics. Under a mnemonic of HEADSS, you ask questions about Home (who lives there, any conflict?), Education (what grade in school, grades)/Employment, Activities (after school, church, sports, music, etc), Drugs (cigarettes/alcohol/illegals), Sexuality (with what gender, how many, what protection), and Suicide (any thoughts of, feelings of depression, access to firearms, etc).

I'd learned the mnemonic, but I thought it was dumb. What teenager was going to tell me about any of these things? I am the man, after all. I persevered because I had to, basically, but inside I felt retarded.

We started into HEADSS with our patient. Home, it turned out, was hectic; mom was always at work, dad was in jail, older brother was out of the house, money was scarce. School was okay, but most of her friends were at her old school. Some of her friends used marijuana, but she denied all drugs. She'd quit sports. She didn't have a boyfriend and wasn't sexually active.

When I asked her, "Have you ever thought about killing yourself?", she didn't even bat an eye. "Well, yes."

I almost fell off the end of the bed where I was perched.

As we probed deeper, we got a history of months of 20+ lb weight loss without effort (documented in the chart from a prior admission; she didn't even care), feelings of guilt, hopelessness, and worthlessness, excessive sadness, tearfulness, extreme worry about her incarcerated father (he'd been in jail over 2 years), grief over a long-deceased grandmother, poor sleep, poor appetite, fatigue, and a desire to be dead. She'd been "forgetting" (ie, refusing to take) her insulin for a while because, as she put it, "what is the point?"

We asked her if she'd tried to talk to anyone. She said her mother said everyone has problems, deal with it; her school counselor and friends told her to pray about it. She'd reached out to several people for help and received none.

We asked her if she had a plan for committing suicide. She told us she thought some of her friends had guns or could get guns; she felt like she could get one to kill herself.

Her DKA resolved in a few days. We had her transferred to an inpatient psych facility to begin treatment for her depression. I don't think I ever forgot to give the HEADSS screening for the rest of pediatrics.

And yet, I didn't think I'd like psych. =-P

Pick Your Scenario

One day, a young woman wanted to sit under a tree. Normally, only the boys sat there, but she didn't think that was fair. After all, it's a free country. So she gathered some friends and went to sit under the tree. The next day, someone had spray-painted the sexist word "C**t" on the tree. The boys responsible for the spray-painting were briefly suspended from school.

Several months later, six different girls were hanging out at school when a boy walked by. He called them sluts and insulted one of the girls in a sexual fashion. One girl hit him in the back of the head, then the six beat and kicked him while he lay on the ground. He had to go to the ER for treatment of his injuries.

Were the women justified?

What if the tables were turned? What if the graffiti had said "D**k" in response to a boy sitting in the girls' spot? What if six boys had attacked a lone girl after she laughed at them and accused one of having a small manhood? Would those six boys be justified in attacking her? Most of us find this scenario more offensive than the first, but I think they're approximately equal.

Is six against one ever fair, no matter what the offending person said about your gender, your sexual orientation, your mother, or your race?

I'm sure you know where I'm going with this. The group called the "Jena 6" did exactly that, attack a lone victim 6:1 (some reports say 5:1) after the victim bragged that one of the attackers had been beaten up by a white man.

If the Wikipedia article is truthful (and I take Wikipedia with a grain of salt), then Jena High School and the town had some racial tension preceding the tree incident (involving three nooses), which got worse in the four months before the assault. The principal recommended expulsion for the noose hangers, but was overridden by the school board, who felt it was a "harmless prank." Perhaps expulsion would have been an appropriate punishment, but some people are calling for felony convictions for commitment of a hate crime for this incident. I'm not sure that this meets criteria for federal conviction, disgusting (and racially-motivated) though this action was.

The sentencing for the six attackers is what troubles most of us. Assault, yes; attempted murder is a bit of a stretch. Conspiracy to commit murder only holds true if they planned the attack, and it sounds spontaneous. Saying that kicking the victim with tennis shoes meets criteria for "assault with a deadly weapon" may be a bit of a stretch, although getting kicked in the head could certainly be deadly enough. The one attacker who has been tried and convicted was only 16 at the time of the crime, yet was tried as an adult. His conviction was overturned on this basis, but he has not been released.

I'm willing to buy possible racism in the prosecutory over-zealousness. It could also be an attitude of "I'm going to crack down on crime so I'll get re-elected", in which case ANY highly publicized violent crime would have been over-prosecuted. Who knows?

What bothers me are statements like this:

JoAnn Scales, who brought her three teenage children on a two-day bus journey from Los Angeles, California, to Jena, made the same point.

"The reason I brought my children is because it could have been one of them" involved in an incident like the one in Jena. (cnn.com)

Um, lady, this could only happen to your children if you teach them that violence is an appropriate response to someone calling you a bad name, and if you teach them that 6:1 (or 5:1) is a fair fight.

I realize Jesse Jackson is an extremist with an agenda, but I disagree with him that "Punishing the teens with probation would have been sufficient" (also cnn.com). These guys committed a violent crime, sent a kid to the hospital, and several of them have prior records. These guys deserve a few months in juvenile detention, if properly convicted.

Therefore, I'm not necessarily all about standing behind these guys. I know our justice system is screwed up, and I'm all for changing it to be more fair. I'm all about charging these guys appropriately, and sentencing them appropriately. If there's no evidence that one of the boys participated, then don't charge him. If they're too young for adult sentencing, then don't try them as adults.

But don't tell me that their crime was "okay" because the victim called them a bad name. "He's an asshole" is not an acceptable defense.

Whoops!

Apparently, somebody called me out on my lack of knowledge about prairie dogs. Shocking, really, as they teach us so much about prairie dogs in medical school. Apparently, my lame attempt at humor went straight over their head. However little I know about prairie dogs, I do know that they can in fact carry the fleas which carry Yersinia pestis; some of the rodents in recent years were infected with monkey pox (they were in captivity) and tularemia (in Texas). Yes, I read Wikipedia. I apologize to any prairie dogs who read this for calling them disgusting disease-ridden vermin, as the correct term is "rodents"; "vermin" may be too discriminatory or prejudicial, and it's definitely not a politically-correct term. My bad!

In Case You Missed It...

...go here to see the complete "12 Medical Specialty Stereotypes" by Michelle at the underwear drawer. As always, she brings the funny.

More Microbiology in the News

http://www.kpho.com/news/14107744/detail.html

Friends, when you are traveling in Arizona or New Mexico (or anywhere, really) where there are prairie dogs, do not play with them. They may look cute, but in reality they are disgusting, disease-mongering vermin who deserve to be shunned. If you insist on playing with these nasty creatures, you may contract the bubonic plague. Yes, the plague, which wiped out most of Europe several hundred years ago. The Black Plague, which is still 50% fatal if you contract the pneumonic form. So, if you play with prairie dogs on vacation, then go home and start feeling "flu-like" symptoms, be sure you tell your doctor where you traveled so you can get the right antibiotics pronto.

In case the above isn't nerdy enough, this article discusses the link between resistance to Yersinia pestis and the HIV virus, which scientists may be able to exploit in future HIV prevention/treatment research.

Yes, this is how I spend my Sunday evenings.

Oh Boy Humberto, Part II

So for the second time in two years, a hurricane turned away from Houston and hit East Texas and Louisiana. Once again, Nature has showed that she hates Louisiana.

Oh Boy Humberto

The Gulf Coast is preparing for Humberto, which formed quickly and is marching in to bitchsmack parts of Texas, including Houston. Hope that those of you in Houston stay dry!

Opportunity Costs in Medicine

I was inspired by this article at Med School Hell to try and explore further the opportunity costs undertaken by those in medicine. The first half of his article is good, as he explains opportunity costs in terms of time spent watching TV, but I felt the second half could use some more concrete examples, so here goes.

Point Number One: Medical school itself has opportunity costs. If I'd graduated college and gone to work for minimum wage ($5.15 when I left college), 40 hours a week, I'd have made $42,848 these past four years. With my degree in psychology, I could feasibly have gotten a job as a research technician (but not much else) with a median salary of $52,000 in my area. So in four years, I'd have made $208,000. In med school, instead of earning money, I'm borrowing it. This data from AAMC shows that a debt of $130,000 in Stafford loans increases to $225,351 by the time it's all paid off. So my total costs so far include my opportunity cost of $208,000, plus $225,351 in student loans, to make $433,351. Ouch.

Opportunity costs for medical school also include: time spent in the hospital when I'd rather have been at home, hours of sleep lost, pounds gained eating bad hospital food, time wasted in horrible lectures when I could have been at the dog park, etc. If you wanted you could calculate how many hours were wasted, assign a dollar amount to my time ($25 at the above salary) and find the product. Let's estimate that I've wasted 8 hours a week in the above activities (a conservative estimate) x 52 weeks in a year x 3.5 years (the end of fourth year will not be such a waste) x $25/hour = $36,400. Now my total cost is $469,751 for four years of medical school, at the end of which I'm 26 years old.

Point Number Two: Residency has costs, too. After spending $469,751 in loans, lost wages, and time wasted, now I have an MD and must complete a residency. As a resident, I'll be paid ~$40,000/year in this area, which is still slightly less than my research technician job. For a minimum of 3 years, then, I'm losing $12,000 per year in predicted wages. If I'm working the 80-hour/week maximum, my wage is ~$9.60/hour, which is much lower than my $25/hour as a research technician. Residency and fellowship can go on as long as you like, basically, with a minimum of 3 years. During this time, that student loan debt is accruing interest. So now, I'm $469,751 + $36,000 (more lost earnings opportunities) = $505,751 down in total costs for attending med school + residency. Residency will carry its own opportunity costs similar to med school--nights on call, lost sleep, time away from family, more pounds gained from bad hospital food, more sanity lost, more time filling out scut paperwork, etc. Let's estimate that at 15 hours/week x 52 hours/week x $25/hour x 3 year minimum = $58,500 for a new grand total of $564,251. Whew!

Point Three: Pick your specialty wisely! Different specialties will have vastly different working hours, salaries, nights on call, etc. Let's make a few case examples.

a) In my area, the median family practice doctor's salary is $158,860. Let's assume best-case scenario, outpatient only, 40 hour workweek, and let's assume that there's no opportunity cost to working 40 hours a week--it's "normal" for a US adult to work that much. As a 29-year-old, I start working in this specialty, and I work until I'm 62 and retire. That's 33 years of earning potential at $158,860 = $5,242,380 - $564,251 = $4,678,129. Of course, that salary level is variable, with changes in Medicare reimbursement, interest, time off for maternity/paternity leave, sabbatical, etc. I'm not smart enough to deal with all those numbers.

b) In the US, the average family practice doctor works 52.5 hours/week (in 2003). That means you're either working both weekend days or you worked 10+ hours each weekday. Here, Fat Doctor details her recent stints of 110+ hour workweeks. At 168 hours in a week, she's getting 58 hours a week to come home, eat, sleep, play with her son, see her husband, go to church, and whatever else she may like to do when not at work (remember opportunity costs???). $158,860 looks a lot better for 40 hours of work, or 52.5, than 110.

c) The average US psychiatrist works 48 hours/week and in my area earns a median income of $172,615. I have to go to one more year of residency, so my new total cost of med school + residency is $595,751. If I work until I'm 62, that's 32 years of earning = $5,523,680 - $595,751 = $4,927,929, with (mostly) better hours than family practice.

d) The average US general surgeon works 60 hours/week (really?) and earns a median income of $289,008 in my area. Their residency is 5 years long and generally more brutal than non-surgical residency: therefore, the opportunity cost of going into surgery is higher. If we redo the calculation for med school + lost wages in residency + 40 hours/week of wasted time (I'm assuming a surgical resident works the "80 hour minimum" and no more) at the rate of $25/hour we get $789,751 for surgical residency. The price of your soul, of course, can't be calculated. If they have 31 years of earning x $289,008 - $789,751 = $8,169,497, which is more than the above specialties but with possibly higher hours. I had a general surgeon tell me I should be able to have a family and a life; however, he worked over 80 hours a week on average and had recently taken a new position because he'd been working even longer hours at his old position.

e) Dermatologists work an average of 45.5 hours/week at a median salary of $227,816 after 4 years of residency. Total lifetime earnings of $6,466,545.

Obviously, these specialties differ in the physical nature of the work involved, the hours worked, amount of call, etc. A surgeon is on their feet all day with few opportunities for meals, breaks, etc, where a more clinic-based specialty may be less physically intense. I also think the opportunity costs of residency training are important to consider. After all, that's 3 to 5 to 7 to 9 to infinity years you can't get back.

I'm certainly not saying doctors don't earn a nice living financially. That research technician at $52,000 makes $2,080,000 in a lifetime. I think I have finally reached the conclusion that Med School Hell was trying to make, which is that a) surgeons make a ton of money but the price of getting there and being a surgeon is really high b) other "ROAD" specialties make good money without the high opportunity costs of surgery c) some primary care specialties make less money with high opportunity costs and d) overall, hours worked is a VERY important piece of choosing a specialty, because it's hard to assign a dollar value to lifestyle. If making big bucks is its own reward, great; if you don't care how many hours you work, great; but if you DO, then look at the whole picture.

Not Just on House...

Apparently, three boys have recently contracted amoebic encephalitis by swimming in very warm Florida lakes. Sadly, all three have since died, because unlike on House, this bug (Naegleria fowleri) is nearly 95% fatal.

So, any time you're going swimming in lake water above 80 degrees Fahrenheit, wear nose plugs, so the trophozoites (shown above) don't swim up your nose to your brain, eat it, and kill you.

Public Service Announcement

If I may direct everyone's attention over to the underwear drawer, Michelle has posted TWO new Scutmonkey comics! With promises of a new serial, "The 12 Medical Specialty Stereotypes." Go NOW.

This concludes this broadcast.

Scary

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Too late to turn back now!