Monthly Archives: April 2013

Medical Tsunami

[NB: The following appeared on the opinions pages of the Philippine Daily Inquirer Vol. 28 No. 137 April 26, 2013 issue, the online version can be found here. It was written by Dr. Leonardo L. Leonidas who retired in 2008 as assistant clinical professor in pediatrics from Boston’s Tufts University School of Medicine, where he was recognized with a Distinguished Career Teaching Award in 2009. He is a 1986 graduate of the UP College of Medicine. All copyrights remain with their respective authors and the Philippine Daily Inquirer]

What will you do if one in a hundred plane flights crashes, resulting in injuries? Will you still fly? Or what if one in a hundred bank transactions results in an error in your balance? Will you still trust your bank? In these two instances, the error rate is much less than 1 percent and is fortunately hypothetical. And the chance of these happening is slim because of the technology we have today.

However, if I tell you that 5 to 15 percent of physicians’ diagnoses, whether they are made in hospital emergency rooms or medical offices, are wrong, will you believe it?

In a survey conducted by a diagnostic decision-support software company, it was found that 35 percent of adults in the United States had experienced a medical mistake in the past five years involving themselves, their family, or friends. Moreover, half of the mistakes were attributed to diagnostic errors. Fifty-five percent of the respondents listed misdiagnosis as their greatest concern when seeing a physician outside the hospital. At the same time, 23 percent of them cited misdiagnosis as the error that concerns them most in a hospital.

In the Harvard Medical Practice Study of 30,195 hospital records, diagnostic errors were blamed for 17 percent of adverse events. In another study of 15,000 patient records from Colorado and Utah, researchers found that diagnostic errors contributed to 6.9 percent of the adverse events.

Goldman and colleagues studied 100 randomly selected autopsies from the years 1960, 1970, and 1980 at one institution in Boston. They found that the rate of misdiagnosis was consistent over time.

Alan Greenspan, in his testimony in the US Congress, used “Credit Crisis Tsunami” as a description of what is going on in our economy today. Similarly, in medicine we are also having a tsunami, but a silent one. And this has been going on for decades.

About 12 years ago while visiting Manila, my wife experienced pain in her right big toe. When we returned to our home in Bangor, Maine, in the United States, her joint pains became recurrent. Then, after several years of seeing four board-certified physicians, she was ultimately diagnosed, with the use of MRI, to have a ruptured meniscus in her right knee. She was then scheduled for knee surgery.

Weeks before her scheduled surgery, our son, who was then in his third year in medical school, came to visit. Because I was not comfortable with the diagnosis of ruptured meniscus, I discussed his mom’s case with him, asking him: “Len, with your background on photography, how can an MRI be false positive?”

Our son explained to me the physics of MRI and some principles in perception. He told me: “Dad, if there is something in front of the meniscus distorting the magnetic rays from the MRI, the radiologist will not see a clear outline of the meniscus.” So I asked him what could actually do that. He said that for one, crystals in the knee could cause a false positive reading. I asked what could account for those crystals, and he replied: “Gout.”

With that information, one week before the scheduled surgery, we made an appointment with a rheumatologist. He took fluid from my wife’s right knee and big toe, and within 10 minutes he had a diagnosis—gout. So I cancelled the surgery, and my wife is now better.

After 37 years of practice in pediatrics and studying this topic, I think that like our financial tsunami of 2008, there are many contributing factors. The first is the way we educate physicians. The model of medical education is still the same today as it was 50 years ago. Our diagnostic tool is dependent mostly on our “unaided” brain. Compared to the pilots who use technology in every aspect of their flights, physicians do not. Many diagnostic errors are the result of poor history-taking during the first visit. Many physicians simply do not have enough time to ask the right questions, or they forget to.

The second is that the medical community has failed to recognize that diagnostic error is contributing to the high cost of care and death. In the yearly medical conferences I have attended, none was devoted to diagnostic errors. At the same time, most medical schools have not included any course on diagnostic errors and how to do outcome studies of their patients. This will change soon because the new dean of the University of the Philippines’ College of Medicine is proposing “Safety in Medicine” as part of the curriculum.

Lastly, the manner by which physicians keep medical records in our hospitals and offices in the Philippines is still mostly in handwritten and dictated notes. We should convert to full, secure relational-based electronic medical records that physicians can do outcome studies with in just a few clicks of the mouse. And the records can be securely accessed by patients at any time.

Medical care is a complicated affair, and the communication between physicians and specialists, physicians and their patients are not yet efficient. An intelligent electronic medical record is the first step to reducing diagnostic errors.

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Chart Wars

After spending four years in med school, one year of internship, three years of residency and some time as a hospitalist, you tend to get the hang of how things work and sometimes writing patient histories and writing orders on the patient chart becomes semi automatic somehow. But sometimes, some things get lost in translation from the native tongue to the standard English language the as the following allegedly actual chart entries in one of the biggest government hospitals might attest to.

Patient has chest pain if she lies over her left side for over a year.

On the second day, the knee was better and on the third day, it disappeared.

She has no rigors or shaking chills, but her husband states that she was very hot in bed last night.

The patient is tearful and crying constantly. She also appears to be depressed.

The patient has been depressed since she began seeing me in 1993.

Discharge Status: Alive but without permission.

The patient refused autopsy.

The patient has no previous history of suicides.

She is numb from her toes down.

While in ER, she was examined, X-rated and sent home.

The skin was moist and dry.

Occasional, constant, infrequent headaches.

Patient was alert and unresponsive.

Rectal examination showed a normal sized thyroid.

She stated that she had been constipated for most of her life, until she got separated.

The lab test showed abnormal lover function.

The patient was to have a bowel resection. However, he took a job as a stockbroker instead.

Skin: somewhat pale but present.

Patient has two teenage children, but no other abnormalities.

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photo taken from http://www.bs757.com


Team

[NB: the following is an original article posted as a status update on a colleague’s Facebook timeline. Permission granted to repost in this blog]

The healthcare team are a group of different medical professionals who attend to a patient’s health. They diagnose and treat illness, alleviate pain and death, provide care and educate patients and relatives. Not one single entity or group in the healthcare team has the right to grab credit or claim that they are more important in the hospital and state that without them the hospitals will not operate. Also not one single entity or group in the healthcare team has the right to belittle another group or entity that has had less number of years in school and and less formal training. Each group has a vital role to play and one cannot fully function without the other. Things like credit grabbing, attention getting, and belittling has nothing to do with the patient’s welfare, which is the sole nature of our job. What each and every entity in the healthcare group should do is shut up, ensure that everyone is doing their jobs and that they are doing the jobs specified for their professions.

They should mutually support and back-up each other for the benefit of the patient and the team. This will allow better patient management, and will also make life a lot easier in this very stressful environment. Complaining and comparing that “my life” is harder than yours or that “I am more important, will get the team and the patient nowhere. Everybody loses. The biggest liabilities in the team are those who have a mindset that they are more important than the other.

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About the author:

Hans Navarra, M.D. is a graduate of the UERMMMC College of Medicine Class 2005 


Doctor, Doctor.. you are sick?

It’s like saying that doctors are people too.. sometimes we tend to forget that as well.

music and musings blog

In an ideal world, all doctors are healthy and lives healthy. Unfortunately, that is not the case. Sad to say we don’t follow our own brand of medicine so to speak. Another thing is that we tend to diagnose ourselves and subsequently treat ourselves. Of course, this is just for small aches and pains. The “bigger” diagnoses, depending on the person, we either refer ourselves to our colleagues or well… we procrastinate. Much like any other person I suppose.

Another issue when doctors get sick is we lose time with patients. More to the point, we lose monetary means especially when you’re strictly in private practice. A day out of your clinic can be a big loss. Good thing for me I work part time in a government hospital. Now even absence from that gets me anxious because at times no one will cover for me. Good thing on my…

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