Monday, March 20, 2017

There are many lessons to be learned from March Madness, but for the sports fan, there is perhaps nothing worse than watching your team lose a close game and not because of the success of an opponent, but because of a referee’s error. Officiating mistakes happen and are usually forgotten, except when they occur at a pivotal moment late in the game, leaving no opportunity for recovery. From a goaltending call that wasn’t made or a travel not called, to a decision on intentional fouls, each team’s fan base will see the exact same slow motion replay and come away with a different truth. It’s not common for NCAA administration to apologize for an error and by then, both teams have gone home and the damage has been done.

In medicine, mistakes are inevitable and while the individual provider aims for perfection, it really is a pipe dream. The complexity of the human body and the way it is attacked by disease, infection and trauma makes for a moving target when it comes to trying to prevent or fix problems. Once upon a time, medical care was mostly diagnosis driven and while doctors could be elegant in deciding what was wrong, they had few tools to treat the things that they found wrong. It’s only been very recently that medical care moved from comfort to cure, but that move has opened the Pandora’s box of error.

There are a variety of errors that are possible in the care of a patient and they mirror what happens on the basketball court. The care provider, whether a doctor in the office, a paramedic in the field or a nurse at the bedside, has to put themselves in the proper positon to collect information, process it and make a diagnostic decision. This is no different than a referee who have to be in position to watch a play, know the rules and make a call. A diagnosis or call is missed if any steps fails.

In medicine, diagnosis needs the information gathering skills of talking to the patient, asking the right questions and performing a physical examination. If the information is misleading, a wrong test might be ordered, driving the diagnosis and treatment in the wrong direction. A patient with indigestion might actually be complaining of pain from the heart and coronary artery disease. If early in the disease process, the patient ignores the symptoms or the care provider misinterprets the symptoms, the opportunity to avert a heart attack might be lost. On the other hand, the indigestion might be gallbladder disease and if that diagnosis is missed, the patient might develop a major abdominal infection. Or just maybe the indigestion is “just” indigestion and heartburn, caused by the reflux of acid into the esophagus. Miss this diagnosis and treatment and chronic reflux can result in Barrett’s esophagus, changes in its lining, that can be a cancer precursor. And these are just the common causes of heartburn; textbooks are filled with plenty more.

The right diagnosis is no guarantee of making the right call when it comes to treatment. While there are guidelines for many situations just like a sports rulebook that lay out the call for most situations. However, it’s hard to know or remember every single nuance, especially when time is of the essence and there are some situations where the rules just don’t apply. There may times at the bedside where decisions have to be made and there are no “best “options. Even if there are, no guarantee exists that picking the right treatment will result in a positive result. A bad outcome does not mean that a mistake was made, and sometimes a mistake happens and doesn’t cause harm.

Mistakes happen in medicine happen but most go unrecognized or unreported; the no harm no foul rule. But medical systems are learning that a near miss is a learning opportunity, to make certain “minor” misses don’t become major disasters. The concept of whistleblowing is encouraged to look for ways to improve and in this way, it becomes the medical equivalent of instant replay. The reporting systems also help sort out what happened when major errors occur and the patient is injured and it often takes a disaster for a system to change.

College basketball may be life and death for some fans and their happiness may depend upon a referee’s call. Some of their mistakes are fixable and can be reversed by instant replay but in many cases, there is only an apology that is issued well after the fans have gone home. Who knew that the same situation exists in medicine. The life, death, happiness paradigm is literally true when it comes to medicine. Mistakes happen and many can be overcome but sometimes all that can be offered is an apology.


Images: NY Post, WCRBtv.com

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getting the call wrong

Tuesday, September 27, 2016

One wonders why anybody would aspire to be a referee. It is a thankless job that somebody has to do, especially in the amateur ranks. There is some glamour in being on the field, ice or court as the best players in the world perform, and in that regard professional referees and umpires are also the best at what they do. Less glamourous are the little league umpires or soccer referees who suffer just as much scorn ads the pros. But it’s the beginning of the week and fans, especially those of the losing team, are vocal in blaming officiating as the cause of their favorite team’s demise.

There are very few sports that have black and white results. Racing against the clock provides an arbitrary score but most team sports are at the mercy of the officials. The same is true in medicine. One would think that doctors could agree on the results of an X-ray, blood test or EKG, but one might be wrong. Black and white don’t often exist in medicine and even grey is often in dispute. Not that one shouldn’t trust test results, but they are just one part of a patient’s evaluation and need to be taken into context.



Let’s consider the basic X-ray. The radiologist can take as long as needed to interpret the images, but the in box is always being filled with new cases to read and there is a time crunch. It’s no different than instant replay; the referees could take forever to review play to the detriment of the game and the enjoyment of the fan. Many studies have looked at the radiology miss rate and it tends to be about 3-5%. Interestingly, that percent stays about the same whether the radiologist quickly looks at the film or whether inordinate amount of time is spent reviewing the images. One study reviewed chest X-rays and defined visual dwell as spending too much time on one specific part of the film. Those who spent too much time had the same error rate as the radiologist who spent less than 4 seconds reading an X-ray. The researchers’ conclusion: “Common experience in radiology suggests that many errors are of little or no significance to the patient, and some significant errors remain undiscovered.”




Like radiologists, cardiologists (heart specialists) often interpret tests without physically seeing and touching the patient. Presumably, a test result is a test result, but just like fans from opposing teams who can’t agree on what constitutes a catch in the NFL, cardiologists reading the same test may come to different conclusions. Echocardiograms are ultrasounds of the heart that help diagnose structural abnormalities. Add exercise (or inject a chemical to get the heart to do more work and the echo can help diagnose narrowing of the coronary arteries. Researchers had two or more cardiologists review echocardiograms and compared their interpretations. In patients with normal hearts and those with bad heart disease, the docs agreed. But is patients with intermediate disease, cardiologists could only agree 75% of the time.

For most patients, diagnosis and treatment involves being touched by a health care provider and test results are put in perspective. Clinical situation and tests have to make sense together and the art of medicine involves interpreting the situation. There may not be a wrong, just a gray shade of not right. This perhaps does not satisfy the Monday morning quarterback since everybody, including medical people strive for perfect. But in the imprecise world that is medicine, black and white don’t routinely exist.

Radiology Quality Institute. White Paper: Diagnostic Accuracy in Radiology 2012

Brady A, etal. Discrepancy and Error in Radiology. Ulster Med J. 2012 81(1).

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