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MY previous article in MJA InSight about risk aversion and overinvestigation hit a nerve with many readers concerned about this trend in health care.
If we want to do something about this culture, we need to accept an important cause — blame and shame.
Although Australian doctors generally do consider the risk of litigation by patients when ordering tests, my observation is that the tendency to overinvestigate often occurs because of the fear of being blamed and exposed for having “missed something” by our colleagues.
In this dysfunctional culture, where it’s not acceptable to ever be “wrong” (even without the benefit of hindsight), it’s tempting to think that doing every test means we will always get it “right”. But that’s the problem — doing inappropriate tests is not right, especially if we have failed to listen to the patient.
No matter how much technology we invoke, it is our human interaction with the patient, and the use of our cognitive skills, that characterise our professionalism.
The potential harm of overinvestigation for fear of missing something is no less important than the harm that can be caused by the further investigation and treatment when a patient test comes back with a false-positive result.
Many doctors have a tendency to chase a diagnosis for every symptom — the ‘’tyranny of diagnosis’’. Yet, sometimes it is more realistic — and logically preferable — to admit that we don’t know the precise pathophysiological cause, provided we can exclude conditions that need urgent treatment. Not every symptom requires immediate management.
The desire for a label for every symptom is not solely the preserve of doctors. It can also reflect a patient’s need for security and certainty. Witness the popularity of many “alternative” therapies, where a pronouncement of a “subluxation” or “deficiency” is made with confidence, therapies are recommended, and the accuracy of the diagnosis doesn’t even enter the discussion. What is the error rate of iridology, or live blood analysis? We don’t even know, because it is the therapists’ confidence that reassures the patient, not their diagnostic accuracy.
Why, then, in medicine, do we hold ourselves and our colleagues to such a high standard of accuracy, even to the point where an asymptomatic person has a diagnosis? Have we created such an expectation for perfection that we are hoist by our own petard? Are we displacing our own anxiety about error onto each other, thankful that it wasn’t us who “missed the diagnosis”?
Philosophical tradition says that wisdom means you neither know nor think that you know. Perhaps it also means knowing what you can and can’t achieve, and being honest about it — to yourself and to others.
Ultimately, the purpose of medical practice is to help others. That requires an acute understanding of human nature, including needs, desires and motivations.
We must apply the same understanding to ourselves and our colleagues, not just our patients, and behave in a humane way towards each other. No more blame and shame.
Dr Sue Ieraci is a specialist emergency physician with 30 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management.
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Thanks for another terrific article, Sue.
“the frequency of investigations is inversely proportional to the seniority of the investigator”
As a radiologist, it is a daily sadness to see the lack of history taking and examination preview prior to requesting radiation based imaging. We really need to increase pretest assessment here guys!!
We we see the CABG surgery changes not mentioned on the CTPA for chest pain..
No mechanism of injury on trauma films
The pregnancy ultrasound but no quantitative beta HCG to allow us a second read result to assess what stage the pregnancy is it based on a reliable biochemical correlate.
Australian medicos need to step up.
the question posed in the voitng poll today pre-empts the fact that there is a culture in medicine today, where some, not all doctors are highly critical of their collegues, for all sorts of reasons, not just failure to diagnose.
It is a sad day for medicine when this sort of lack of professional support exists.
There were critical comments made of Dr Jayent Patel at the time of the beginning of his court case, from the ranks within the profession. Time has shown that this case should never have come to the attention of the courts. He was wrongly accused. This case did show the shortcoming of the medical bureaucrats set in place to monitor the profession. There may have been issues with his practice, but he was seen as “all that was wrong with the profession in Qld” and in some ways used as a scapegoat. It took the courts to see that justice was done.
Unfortunately, in this world, people do make mistakes, doctors do miss things, clinical signs change / become more apparent with the progression of time. BUT, some doctors LOVE to point the finger at other doctors as a means of one-upmanship. “Dog eat dog”, is an apt description.
Medicine is in a v sad state of affairs in 2014.
Failure to Diagnose
I have yet to meet a medico who has not missed a diagnosis. The main failures, as Sue Ieraci intimates, are not listening carefully to or fully examining a patient, thinking about the possibility of a diagnostic entity or stubbornly sticking to a diagnosis when the patient fails to respond to increasing doses of the same treatment.
Other causes of missed diagnoses are agreeing to see too many patients, rushing them, not perusing their previous medical notes, failing to follow up on sick or undiagnosed patients, not discussing difficult patient problems with colleagues, and assuming that patients referred to hospitals or specialists will receive a 100% accurate diagnosis and follow-up.
A blunderbuss approach to investigations is not a substitute for thinking and cursorily read results can be another cause of missed diagnoses.
If a surgeon had a 5% positive result for removed appendices he would be held up to ridicule by his peers. High investigating doctors with a low diagnostic yield would also benefit from an audit of their investigation results.
The Golden Rule of medicine is to do the best you can for your patient.
The Silver Rule is to do so without bankrupting the health budget.