Tuesday, March 8, 2011
Regardless of the crowd, the atmosphere and the tradition, the best seat in the house is in front of the television. Cameras zoom in on the field of play. Replays in slow motion show the action from different angles and inevitably, no matter what team you cheer for, the referee is always wrong. Hindsight tends to be 20/20 and that axiom is especially true in medicine. Given the same information, two doctors might come up with opposite opinions.
Caring for patients is a four step process. Information gathering is step one, followed by step two, data interpretation and diagnosis. Treatment is step three and finally there is step four, the post-treatment analysis. In regular English, the doctor needs to learn the story and examine the patient. That may be all that is all that is needed to make the diagnosis and lead to treatment. Tests may be needed to clarify the diagnosis or potentially muddy the situation if they don’t support the working diagnosis. But once treatment is completed, a review or recheck may be appropriate to make certain that recovery has occurred from the illness or injury.
Modern medicine has come to rely on technology to guide diagnosis, even though talking with the patient will often reveal what is going on. Taking a history and asking the right questions can guide a focused physical examination. Too often, though, the fear of missing a potentially catastrophic illness leads to the use of excess testing and the potential complication of discovering an incidental finding that takes the diagnostic process on a wild goose chase. It is enticing to leave a paper trail of blood tests and x-rays in case something goes wrong, instead of the less tangible clinical judgment option. When something goes wrong, peer review looks not only at what tests were ordered, but why they were ordered and how the results were interpreted and acted upon. Ordering the wrong test can be just as catastrophic as not ordering it in the first place.
It is easy to cast blame when looking back at medical care. It is much more reasonable to try to follow the chain of events chronologically, like reading a detective novel. Reading the last page of the book before the first chapter, colors how clues can be interpreted when they are revealed. If one knows the diagnosis is heart attack, it makes it much easier to recognize that the patient’s complaint of indigestion may have been angina. If the doctor ignored other complaints like shortness of breath or passing out, then perhaps an error occurred. But common things are common and most patients with indigestion have indigestion .They should not be admitted to the hospital to get their heart checked out. To take the caution argument to the extreme, appreciate that a third of heart attack victims have no symptoms but who would agree to invasive tests if they felt fine.
Errors in diagnosis are especially difficult for patients to understand. The information may be available to the doctor but the interpretation of the data comes to the wrong conclusion. However, medicine is rarely black and white. Radiologists agree to disagree two percent of the time when they read x-rays, CT scans and MRIs. Pathologists who evaluate slides looking for tumors and cancers may need second opinions and specimens are often sent cross country for second opinions. Even basic blood tests can be confusing. The white blood cell count tends to be elevated and abnormal with infection except when that infection is overwhelming and the white blood cell decreases. But an elevated white blood cell count does not mean infection or inflammation. It also goes up in times of stress like in trauma or when a patient gets a shot of adrenalin for an allergic reaction. The result needs to be placed in context and things need to make sense and again judgment needs to be used. If the test result doesn’t fit the scenario, either the test is wrong or the story is wrong and it’s time to start over.
Do overs don’t happen in sports, nor are they routine in medicine. Winning teams overcome referee errors and find a way to win. Good patient outcome may have to overcome pitfalls and unexpected complications. Medications can cause side effects. Incisions can become infected. Mistakes can happen. Officials talk to each other on the field to get their calls right. Doctors need to explain their thinking and judgments to the patient and the patient needs to ask enough questions to understand what’s going on.