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The Last Doctor is Always the Smartest

Twice recently, I’ve been privy to patient complaints about emergency department “misdiagnoses” when patients have gone to follow up appointments with their physicians.

ExanthemOne case involved a young girl who had a rash. The rash was preceded by a low grade fever in the days prior, began on the chest and spread outward, and had the classic appearance of a viral exanthem. The girl’s parents weren’t happy with that diagnosis. They believed that the girl was suffering from an allergic reaction and that she needed antihistamines and steroids. The doctor explained that the rash was not an allergic-type rash and that she didn’t appear to be ingesting anything that could have caused an allergic reaction. The family left unhappy. The following day, the nurse manager gets a phone call from the patient’s irate mother. During a follow up appointment the following day, the patient’s pediatrician stated that the rash was “absolutely” an allergic reaction and immediately started the patient on Benadryl and prednisone. Oh, and the patient also had an ear infection that the emergency physician missed, so she was started on amoxicillin as well. The money quote for that call was “What type of doctors do you have working in your hospital, anyway?”
Of course, the natural course of an exanthem is that it will go away after a couple of days. So right after the patient starts taking the medications for her “allergic reaction,” her rash will get better which will reinforce the “post hoc ergo propter hoc” logical fallacy. Of course, the patient could have been given magic beans and eye of newt and she would have had the same outcome (perhaps with a little bit of an added sour stomach from the eye of newt), but it doesn’t matter because according to the pediatrician, the emergency physician misdiagnosed the cause of the rash. Of course if the patient happened to have a reaction to the amoxicillin, then the logical conclusion would be that the delay in treatment by the emergency physician caused the allergic reaction to get worse. So regardless of the outcome, the emergency physician comes out looking like a bad doctor.

CT BrainAnother case involved a patient with a severe headache. He was seen by his primary care physician and diagnosed with sinusitis. The following day, the headache had not improved on Augmentin and nasal steroids, so the patient came to the emergency department. Because it was a new-onset severe headache in a patient who never had headaches before, the emergency physician ordered a CT scan of the head. After some Imitrex and some Compazine, the headache resolved. The CT scan showed no abnormalities – including absolutely clear sinuses. Based on this, the emergency physician told the patient that he probably was suffering from migraines that he could stop taking the Augmentin and nasal steroids because the sinuses were normal on the CT scan.
Two days later, the patient returned to the emergency department in person so that he could loudly tell the registration clerks that they better watch that “dangerous doctor” working back there. A nurse intervened and the patient told her that his primary care doctor told him the emergency physician was absolutely wrong and that sinus infections absolutely can occur even without any abnormalities on CT scan, and that he needed to finish the antibiotics and keep taking the steroids — which he had thrown away after his emergency department visit. His next stop was allegedly to a lawyer’s office to look into suing the hospital.
It doesn’t matter that the medical literature shows that antibiotics and nasal steroids are ineffective as treatment for acute sinusitis. It doesn’t matter that the acute sinusitis resolved with migraine medications. It doesn’t matter that the sinuses were normal on CT scan. It only mattered that the patient’s physician was able to explain away the care rendered in the emergency department as being incompetent in a forum where the emergency physician was not present to defend himself from the criticisms.

These cases aren’t intended to illustrate that emergency physicians are always right.

Rather, they are intended to show how, even when the opinions are wrong, there is a tendency to believe that the last opinion is the correct one.

Not true.

They are also intended to show how behavior by subsequent treating physicians can anger patients and potentially lead to lawsuits.

In fact, one of these scenarios upset the emergency physician so much that there was an ethics complaint made to the hospital administration. I’d like to be a fly on the wall at that meeting.

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This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

One Response to “The Last Doctor is Always the Smartest”

  1. Joe says:

    This happens all the time! The same PCPs who throw the EM Physicians under the bus, are also the same ones who send their patients to the ED, with a chief complaint of ” the doctor sent me in”.

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