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Demanding Perfection?

Want more evidence about how many people expect perfect outcomes in medical practice?

Look no further than the Wall Street Journal: “What if the Doctor is Wrong?” by Laura Landro.

As a substantive basis for the conclusion that initial treating physicians are “wrong” when they haven’t yet reached a diagnosis, Ms. Landro interviewed two patients who, in the midst of a workup, left the doctor who was trying to diagnose and treat their problems. Said patients then went to a “mecca” to have their workup completed where … amazingly … the problem is “discovered” and “properly” treated. Even though the initial provider in all likelihood would have done the same testing that the “mecca” performed after reviewing the results of the initial testing – had the patient stuck around long enough to have the testing performed. Even though the “standard of care” may have been to do things exactly the way that the initial provider was doing them. Nope, they’re wrong because they didn’t get to the answer sooner.

When reading about all these “errors” I couldn’t help wondering: Did Ms. Landro have a neutral physician review the patients’ medical records to see whether the care provided to the patients was appropriate? Did Ms. Landro interview the initial treating physicians to determine what the next step in their treatment plans would have been? If so, she kind of left those points out of her article.

I understand the idea that second opinions can be useful and I agree that misdiagnoses are sometimes made. Until we find a single test that is 100% sensitive and 100% specific for diseases such as cancer or complaints such as abdominal pain, there will always be misdiagnoses made. Even once a diagnosis has been made, there are disagreements about how to proceed with treatment. Some prefer one medication for treating certain types of cancer, some prefer another medication. Does that make one side “wrong” and the other side “right”? Hardly.

The title of this article and the slant of this reporting make it appear as if doctors are “wrong” just because they don’t make a diagnosis after the first round of testing. Did Ms. Landro even explore how often the “meccas” get their diagnosis “wrong” on the first visit? Are the “meccas” that much better?

If patients want to mortgage their house to get the tens or hundreds of thousands of dollars necessary for a “down payment” at MD Anderson (original link to WSJ article here) or some other “mecca” when they likely would have gotten similar testing done had they stuck with their initial providers, that’s free market medicine at work.

When journalists imply that excluding diseases on a list of differential diagnoses in the midst of a workup or coming up with “inconclusive” results during testing is “wrong”, shouldn’t we start looking into journalistic malpractice?

What if the Journalist is Wrong?

9 Responses to “Demanding Perfection?”

  1. Wayne Conrad says:

    I expect my physician to be imperfect. The first diagnosis may be wrong. The first treatment may not be effective or might have unacceptable side-effects. That’s alright. It comes with the territory when a person is asked to diagnose and treat a problem with a complex machine given limited and sometimes misleading data.

    I make a living doing that–that is, diagnosing and treating problems with complex machines given limited and sometimes misleading data. My machines are computers instead of people, but I fancy that the process of gathering data, generating and testing hypotheses, and trying fixes (all while doing your best not to harm the machine) is much the same.

    I sometimes think of my physician as my “medical bookie”, an expert who can lay odds on the cause of my ailment, and on which treatment is most likely to help what I probably have and least likely to cause me harm.

  2. Sarah says:

    I work in the ED at an east coast Mecca O Medicine, and we get these patients all the time–often on Saturday overnight shifts, for some reason. They drive from 10 hours away to get admitted for a chronic problem after an extensive work up through their home medical system yields nothing, and they come for our miracle. I discharge well over half them (this goes over poorly), and the ones who get admitted are rarely actually diagnosed with anything. Their outside workups generally sound reasonable. Rarely do we have anything extra to offer besides another set of doctor’s eyes. I doubt that I have any magical diagnostic ability that a community ED doc lacks.

  3. Marilyn B. says:

    I don’t expect perfection from my doctor, but I certainly expect a reasonable response to reasonable questions. I don’t understand why doctors are resistant to testing a patient might ask for, if there are good reasons for asking.

    Especially if the patient is willing to pay out of pocket.

    I expect my doc NOT to have a god-complex, and many do. I respect their education, but some of them are donkeys. And not all patients are idiots who make wild guesses about their health based on brief consultations with Dr. Google.

  4. midwest woman says:

    If a insurance company denies a second opinion or diagnostic test because it seems out of he box but which might have produced a more optimal outcome, can they be sued?

    • ERDOC1 says:

      No. They are protected by a federal law called ERISA. They are protected even if they refuse to pay for a TREATMENT that may be of benefit

      • midwest woman says:

        Wow

      • Matt says:

        Assuming they’re an ERISA plan, of course. If you buy your health insurance privately, they may not be. Large employer plans generally are.

        However, “might have produced a more optimal outcome” is not much of a basis for a claim. When you sue an insurer, you really want it to be based in contracts law – ie. you AGREED to cover this and now you’re breaching that agreement. Let the debate be on the specific procedure’s inclusion in the coverage language. The outcome matters for damages, but again, you’ll need something stronger than “might have”.

  5. Lisa K. says:

    So when would you recommend getting a second opinion? I understand that most doctors give very good care most of the time. But how are patients supposed to know when they are not getting good care? Patients can judged bedside manner but they don’t have the knowledge base to make good judgements on their doctor’s clinical decision making.

  6. Kim says:

    I am a long time reader of your blog. I came across a TED talk today that I feel you and your readers may enjoy watching. It addresses the reality that all professionals make mistakes, and that doctors and other medical providers should be able to talk about them in a shame-free environment.

    http://www.ted.com/talks/brian_goldman_doctors_make_mistakes_can_we_talk_about_that.html

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