December 29th, 2010 by KevinMD in Better Health Network, Opinion, True Stories
Tags: 15-Minute Office Visit, Clinical Judgment, Consideration of Symptoms, Dismissing Symptoms, Dr. Danielle Ofri, Dr. Kevin Pho, Family Medicine, General Medicine, Internal Medicine, KevinMD, Medical Malpractice, Minimizing Symptoms, Misdiagnosis, New York Times, Not Enough Time For Patients, Patient Care, Patient Complaints, Patient Concerns, Patient Questions, Patients Who Worry Well, Primary Care, Prioritizing Patients' Complaints, Questions To Ask Your Doctor, Rushed Office Visit, Signs and Symptoms, Telling Your Doctor About Symptoms, Underdiagnosed, Wrong Diagnosis, Wrong Medical Decisions By Doctors
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Primary care physicians often have to see patients with a litany of issues — often within a span of a 15-minute office visit.
This places the doctor in the middle of a tension: Spend more time with the patient to address all of the concerns, but risk the wrath of patients scheduled afterwards, who are then forced to wait. And in some cases, it’s simply impossible to adequately address every patient question during a given visit.
It’s a situation that internist Danielle Ofri wrote recently about in the New York Times. In her essay, she describes a patient, who she initially classified as the “worried well” type:
… a thin, 50-year-old educated woman with a long litany of nonspecific, unrelated complaints and tight worry lines carved into her face. She unfolded a sheet of paper on that Thursday morning in my office with a brisk snap, and my heart sank as I saw 30 lines of hand-printed concerns.
Ms. W. told me that she had recently started smoking again, after her elderly mother became ill, and she was up to a pack a day now. She had headaches, eye pain, pounding in her ears, shortness of breath and dizziness. Her throat felt dry when she swallowed, and she had needling sensations in her chest and tightness in her gut. She couldn’t fall asleep at night. And she really, really wanted a cigarette, she told me, nervously eying the door.
This is the kind of patient who makes me feel as though I’m drowning.
Dr. Ofri did as many doctors do: She listened appropriately, went over the patient’s history and physical, reviewed prior tests, and concluded that many of her symptoms were due to anxiety. Except, in this case, they weren’t. The patient eventually had a pulmonary embolus, and hospitalized. Read more »
*This blog post was originally published at KevinMD.com*
December 29th, 2010 by GarySchwitzer in Better Health Network, Health Tips, News, Opinion, Research
Tags: Accuracy of Medical Decision Making, American Healthcare System, Becoming A Savvy Healthcare Consumer, Dr. Kent Bottles, Empowered Patients, Evidence-Based Healthcare Decisions, Gary Schwitzer, Good Medical Decision Making, Health Media, Health Reporting, Health Sciences, Health-Savvy Patients, Healthcare Decision Making, Healthcare Decisions, HealthNewsReview.org, Limitations Of Science, Making Good Health Choices, Media Coverage of Healthcare, Medical Media, Medical Reporting, Patient Empowerment, Personal Health Decisions, Responsibility in Healthcare, Science And The Media, Science Based Medicine, Science In Medicine, Science Reporting, Shared Decision-Making
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Dr. Kent Bottles is in the midst of a very thoughtful multi-part blog post under the heading, “The Difficult Science Behind Becoming a Savvy Healthcare Consumer.”
Part I examined “the limitations of science in helping us make wise choices and decisions about our health.”
Part II explores “how we all have to change if we are to live wisely in a time of rapid transformation of the American healthcare system that everyone agrees needs to decrease per-capita cost and increase quality.”
Both parts so far have addressed important issues about news media coverage of healthcare. Read more »
*This blog post was originally published at Gary Schwitzer's HealthNewsReview Blog*
December 28th, 2010 by Dinah Miller, M.D. in Better Health Network, Opinion
Tags: Accuracy in Diagnosis, Diagnosis Error, Dr. Dinah Miller, Early Closure, My Three Shrinks, Psychiatry and Psychology, Shrink Rap
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Meg sent me a link to Happiness in The World (what an upbeat name for a medical blog!) and The Danger of Early Closure. She wanted to know how it pertains to psychiatry. The author writes:
Sometimes doctors gather all the clues correctly, think all the right things based on those clues, and still get it wrong. But in this case, another significant thought error contributed to the misdiagnosis: My tendency to come to early closure.
Early closure, it turns out, is a danger that lies in wait mostly for seasoned clinicians (far more commonly, at least, than for medical students and residents). Because seasoned clinicians rely more on pattern recognition to make diagnoses and often come to their conclusions rapidly, they’re at far greater risk for leaping toward those conclusions without examining all other should present (luckily for us all, this is the exception and not the rule).
At other times, however, these mistakes are made because the physician was simply in a hurry, or tired, or didn’t care enough to think through the evidence in ways he should have, saw a pattern he thought he recognized, and stopped asking the most important question a physician can ever ask: What else could this be? Read more »
*This blog post was originally published at Shrink Rap*
December 28th, 2010 by GruntDoc in Better Health Network, Opinion
Tags: Better Patient Care, Dr. Allen Roberts, ED, Electronic Medical Records, Emergency Department, Emergency Medicine, Emergency Room Care, EMRs, ER, GruntDoc, Hospital Systems, Kaiser Health News, Public Health, Shared Patient Information, Too Many Tests, Unnecessary Medical Tests, Unnecessary Testing
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Via Kaiser Health News:
On a recent Friday night at the Boston Children’s Hospital ER, Dr. Fabienne Bourgeois was having difficulty treating a 17-year-old boy with a heart problem. The teen had transferred in from another hospital, where he had already had an initial work-up — including a chest X-ray and an EKG to check the heart’s electrical activity. But by the time he reached pediatrician Bourgeois, she had no access to those records so she gave him another EKG and chest X-ray. He was on multiple medications, and gave her a list of them. But his list differed from the one his mother gave doctors, neither of which matched the list his previous hospital had sent along.
This is excellent advice. Every ED has seen a patient, probably today, with “they saw me at the ER across town, but they didn’t do anything and I’m still sick.” While it makes some sense not to return to a restaurant that gave you a meal that wasn’t to your tastes, medicine is quite different.
If a patient gives me this history, I now have a blank slate, and need to essentially start at zero with them. So, I will do the correct workup to exclude the life threats based on the history and physical exam, which may be exactly the tests they had yesterday. I’m not going to assume they did the same tests, or that they were normal. It’s the standard of care at this time, and I have very, very few alternatives. Read more »
*This blog post was originally published at GruntDoc*
December 28th, 2010 by RyanDuBosar in Opinion, Research
Tags: ACP Hospitalist, AF, American College Of Physicians, Annals Of Internal Medicine, Anticoagulants, Anticoagulation, Atrial Fibrillation, Blood Clotting, Blood Thinners, Cost of Medications, Dabigatran, Dr. Juliet Marvromatis, DrDialogue, Drug Costs, Drug Efficacy, Emory Healthcare, Emory University, FDA, Food and Drug Administration, Healthcare Economics, Hospital Formularies, INR, International Normalized Ratio, Patient Safety, Pharmacology, Primary Care, Prothrombin Time, PT, RE-COVER, RE-LY, Rivaroxaban, Ryan DuBosar, Stroke Prevention, The Business Of Thinning Blood, VA, Veterans Administration, Warfarin, Ximelagatran
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This is a guest post by Dr. Juliet Mavromatis:
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The emergence of a new generation of anticoagulants, including the direct thrombin inhibitor, dabigatran and the factor Xa inhibitor, rivaroxaban, has the potential to significantly change the business of thinning blood in the United States. For years warfarin has been the main therapeutic option for patients with health conditions such as atrial fibrillation, venous thrombosis, artificial heart valves and pulmonary embolus, which are associated with excess clotting risk that may cause adverse outcomes, including stroke and death. However, warfarin therapy is fraught with risk and liability. The drug interacts with food and many drugs and requires careful monitoring of the prothrombin time (PT) and international normalized ratio (INR).
Recently, when I applied for credentialing as solo practioner, I was asked by my medical malpractice insurer to detail my protocol for monitoring patients on anticoagulation therapy with warfarin. When I worked in group practice at the Emory Clinic in Atlanta I referred my patients to Emory’s Anticoagulation Management Service (AMS), which I found to be a wonderful resource. In fact, “disease management” clinics for anticoagulation are common amongst group practices because of the significant liability issues. Protocol based therapy and dedicated management teams improve outcomes for patients on anticoagulation with warfarin. Read more »
*This blog post was originally published at ACP Hospitalist*
