Thursday, September 27, 2007

The Empowered Patient

Today, 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?

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.


The Gonzfather said...

<-- Rolling eyes at your "period" pun; yet also very jealous of the cleverness behind it.

Tiny Shrink said...

It was pretty good, eh?

JC Jones MA RN said...

Very thoughtful commentary...

Tiny Shrink said...


Lapa said...

You'r welcome