Misdiagnosis, the 98/2% rule, and other ramblings.

By cw99, May 29, 2017

This is in response to Helen’s question:
Hello, Dr. casey:
I don’t want to be viewed as a troubl maker, but realistically what % would you assign to prior misdiagnosis / mistreatment?
I read that the number is not negligible.
With all my respect and affection for the docs who have graced Gummune,
Helen

No offense taken. I will gladly try and expound upon the 99%/1%. In all honestly, I was obviously being mostly facetious. I think the good doctor’s point was that if you take all comers in a given practice and try to explain the etiology of their particular illness or chronic medical condition 98% can be explained by under activity, over nutrition, and self-abuse. I don’t think it really has much to do with misdiagnosis/mistreatment. What you’re referring to is something KSS mentioned one or two articles back. If I remember correctly, it was something on the order of 40% (maybe even 80%) of patients who returned unexpectedly after a primary care visit were initially misdiagnosed.

What does that mean exactly? Well, not having actually read the research article myself, I can’t say exactly, but I have a pretty good idea (regarding misdiagnosis). I can give countless examples; most will have no long-term repercussions on the patient’s outcome or overall health state.

1. Let’s say for example Mrs. Jane Doe presents to her PCP for urinary frequency, dysuria, urgency, and mild flank pain. He runs a UA and returns a diagnosis of a bladder infection. He prescribes antibiotics. She returns 3 days later to his office or to an ER for severe right-sided flank pain. It turns out she actually has a kidney/ureteral stone. She continues the antibiotics and passes the stone 1 day later. No long lasting effects. Whether or not it was diagnosed on the 1st visit is irrelevant.

2. John Doe sees his PCP because he felt lightheaded for about 20 minutes yesterday. Routine blood work and an EKG are normal. He is sent home, only to return the next day this time with active symptoms. A repeat EKG is done, and he has atrial fibrillation. He is sent to the hospital, his rate is controlled, and he has a cardiology consult. He is discharged the next day and ultimately does well.

3. James Doe sees his PCP for sinus congestion, is diagnosed with a sinus infection, and is given antibiotics. He returns a few days later for no improvement. Turns out he has simple seasonal allergies and improves with Flonase, Prednisone, and nasal saline rinses.

4. Jeremy Doe bangs his elbow on a doorframe. Sees his PCP, X-ray is negative, and he is diagnosed with an elbow contusion. He returns 2 weeks later and is diagnosed with olecranon bursitis.

5. Finally, Jennifer Doe sees her PCP for “indigestion”. She is diagnosed with GERD. She returns to an ER that same night with worsening and is diagnosed with a STEMI (heart attack). Or let’s say she saw a gastroenterologist 2 weeks later in follow-up and an EGD revealed peptic ulcer disease.

This was most likely a retrospective study. A study in which they reviewed the records of let’s say 25 primary care practices. They then perhaps set a parameter such as UNSCHEDULED return visits within 1 to 2 months. They then simply compared the 1st diagnosis (per above examples; UTI, dizziness, sinusitis, elbow contusion, and GERD) to the 2nd diagnosis; (ureteral stone, atrial fibrillation, seasonal allergies, olecranon bursitis, and peptic ulcer disease). If the 2 diagnoses didn’t match, then it was considered a misdiagnosis.

Considering the vast pathology that can occur in the human body, I’m surprised the misdiagnosis rate isn’t much higher (maybe that article KSS was referring to was 80%). That still would not be surprising. Remember they were reviewing primary care practices. The number of misdiagnoses would dramatically decrease if you were to review charts of subspecialists (rheumatologists, pulmonologists, gastroenterologists, orthopedists etc.). Why? Well, some of the work has been done for them already, and they have more capabilities at their disposal.

The number of misdiagnoses from an ER is probably less as well …I say probably only because from an Emergency Medicine standpoint we don’t necessarily care about what is causing your problem so much as what is not causing your problem. Well, we too have almost an unlimited array of diagnostics at our disposal. If someone comes in with a sudden onset of headache with or without a history of hypertension, you can be damn sure they are going to get a head CT (and probably a CTA head). Before they leave that ER we have ruled out SAH or any bleed for that matter, hydrocephalus, aneurysm, and anything infectious. So, without a doubt, I can tell you that you don’t have a tumor, a ruptured aneurysm or meningitis causing your headache. Your discharge paperwork will probably just say HEADACHE. We/I know there are different types of headaches…migraine, complex migraine, migraine with or without aura, tension HA, cluster HA, sinus headache…. and while we attempt to give you an accurate diagnosis, in the eyes of an ER doc…we don’t really care. We’ve determined your HA is not going to kill you. Adios sucka. We’ve got plenty of drunks, vaginal bleeders, overdoses, chest pains, and abdominal pains to see. And although frustrating at times for the patient to not have an accurate diagnosis, I would say most are happy to find out what is NOT causing their symptoms.

Now imagine the poor primary care doctor. His patients DO expect a diagnosis. If she has diagnosed someone with a tension headache, and it turns out they really had a complex migraine headache….well, that counts as a misdiagnosis. PCPs are under immense pressure to keep costs down by not ordering as many tests. They often fall into the lull of just keeping patients “maintained”. Biannual visits to check on Mrs. Johnson’s blood pressure and cholesterol. They often fall out of practice when having to deal with too acute of a problem. In addition, many PCPs offices are being staffed by poorly trained and under experienced nurse practioners (no hate mail please…I work with and know PLENTY of talented PAs and NPs).

What does all of this have to do with the 98/99% of any medical practice and its patients who have overnutrition, under activity, and self-abuse?

Absolutely nothing. The physician’s ability to get the right diagnosis on the first attempt has nothing to do and does not change the patient’s underlying disease. If you have diabetes and are not diagnosed on one particular visit…you will STILL have diabetes on your next visit.

What are the major health problems facing this country?

Heart disease….fatty diet, smoking and lack of exercise
Diabetes…obesity (some is genetic)
Respiratory Disease (COPD)…smoking
Cancer…mostly genetic and luck (except for HCC, skin cancers due to self-abuse)
Stroke…fatty diet, smoking and lack of exercise (same as heart disease)
Hypertension…smoking, fatty diet, lack of exercise
Liver disease…alcohol, poor diet, drug abuse, risky sexual practices
Kidney disease…smoking, drug abuse, noncompliance with medication
Trauma…alcohol, violence, risky behavior (yes, I know there are “accidents”)

Of course, if everyone suddenly became a Monk, most physicians would be out of a job. One would think it is an oversimplification to attribute 98% of disease in this country to OVERNUTRITION (get that damn burger and mac and cheese out of your mouth), UNDERACTIVITY (try walking or taking the stairs) and SELF-ABUSE (stop smoking for crying out loud, it’s OK to drink a LITTLE, stop doing drugs, stop unsafe sexual practices), but really I think that is spot on. I see it EVERDAY single day I walk through those doors that say EMERGENCY. Anyone who begs to differ…I’m sorry, but you’re delusional (this is NOT aimed at you Helen…I’m just speaking in general terms).

This is a discussion topic or guest posting submitted by a Stock Gumshoe reader. The content has not been edited or reviewed by Stock Gumshoe, and any opinions expressed are those of the author alone.

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arch1
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Dr Casey thank you for starting this blog, I have always admired those in ER as I used to be one who scraped people off the side walk and dumped them on you [fire service] and I agree with what you write here. Things have certainly changed during the last century as over nutrition was not a problem in the 1930s and seems to me to be mainly since 1960s burgeoning of fast food, pizzerias, taco stands, fried this and that. Much more risky behaviour and substance abuse, less work accidents and lower per capita deadly auto accidents. I think… Read more »

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petervr
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petervr

Casey, I do not feel anything is as stimulating as a complex subject being discussed by truly well educated, intelligent people. The point is not really the conclusion, but the artistry demonstrated in getting there. This is entertainment of the highest order.
PetervR

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biotechlong (btl)
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Thank you for sharing your experience-based insight, Casey. I would also expect that the time pressures on PCPs to see X # of patients per day (AND complete ever-increasing documentation) – resulting in the “15-minute per patient time limitation” that seems almost universally prevalent in primary care medical practice – renders it virtually impossible for the PCP to realistically adhere to any standard other than “routine maintenance” in 95% of outpatient visits. In my experience (as an increasingly frequent participant in professional health care services rendered to my wife and I), the phenomena that elevate a case to a higher… Read more »

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mary
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mary

You are so right; most of us are frustrating to deal with…our own worse enemies!