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Online discussion on medical mistakes
Dr. Brian Goldman and reporter Erin Anderssen took readers' questions
- Welcome to today's discussion. Joining us is The Globe and Mail's Erin Anderssen , who wrote a story about medical mistakes that appeared in Saturday's paper. In it, she tells how her husband's lyme disease was misdiagnosed. (Read her story here: www.theglobeandmail.com)
Also joining us is Dr. Brian Goldman, an emergency-room physician and host of the CBC radio show White Coat, Black Art. He recently gave a TED talk on the subject, which you can view here: www.youtube.com - I'm happy to be invited to comment on what I think is one of the most important areas in medicine: creating a culture of safety.
- Our first comment today is from reader Gordon Tait.
- Based on a recent paper in Academic Medicine by Ely, Graber and Croskerry which recommended a diagnostic checklist to prevent errors of failing to consider all the alternatives, we created Web site (http://pie.med.utoronto.ca/dc) to make the checklist items available online with a couple of click of the mouse. There is a mobile-friendly version that works for smart-phones.
In the case of Joel’s visit to emergency described in the weekend article, if you click on “Rash” as the presenting complaint, “Lyme disease” appears as a “Do not miss” diagnosis that should be considered. “Lyme disease” is also flagged as a possible cause for numbness, sensory loss, myalgia and arthralgia.
I wondered what you thought of this type of online tool for helping to prevent diagnostic error? - Checklists are a good way to reduce errors. Peter Pronovost, a critcal care specialist at Johns Hopkins in Baltimore develoed a checklist to prevent infections in procedures done in the ICU. The checklist has been proven to save lives.
- Hi Erin & Dr Goldman, I have told my story to Dr Goldman before, I was ill for four years and winding my way through Doctors before I found the name of a doctor in the US who I saw, was diagnosed in short-order and told next steps. My biggest beef with the doctors here was 1. They did not want to hear about information I found on the internet about my rare condition; 2. They kept their diagnosis criteria to limited scope (eg my spinal tap number wasn't high enough to be considered a problem); yet I got better after a spinal tap; they sent referrals with their own predjuices following the referral. These three criteria I believe slow down our system. When 1 in 12 have a rare disorder/disease it is no wonder our system is so bogged down.
- I'd love to to see electronic medical records (EMRs) have decision support tools that include friendly reminders. The Veterans Administration in the US has a good system for decision support that reduces errors and costs the system less $.
- Dr. Goldman, could you give us a sense of the scope of the problem of medical mistakes in Canada and what the consequences are?
- @Ruth Knight-Bowes You're right. As Erin pointed out in her article on Saturday, rare diagnoses are less likely to be detected.
- @Danielle Adams A study by Baker and Norton published I believe in 2004 found that preventable medical errors kill between 9,000 and 23,000 Canadians per year. I believe that's an underestimate since the data did not include long term care facilities. The leading causes of preventable deaths include hospital-acquired infections and drug-related errors (wrong drug, wrong dose of drug, etc). The drug error rate is around 1 in 10 - which is the same in Canada as in most Western nations regardless of public vs private systems.
- @Gordon Tait This is a great tool. But remember, it's not just the tool but the person using it that's important.
- I have been reading alot about the Participatory Medicine model, I think it is time that doctors start opening up to patients bringing information into the appointment, I know there is concern about hypochondriacs etc, but there is a time, place, and patient to share information. When I saw my neurosurgeon here, he was the first doctor to say: I bet you've been on the internet and know alot all ready - opened the door for me to say yes and feel comfortable discussing internet research.
- Erin Anderssen is joining us now.
- At certain hospitals in the US, they have started an electronic symptons that will flag to doctors potential illnesses they have missed, or additional test they might want to run and prompt them with questions of symptoms or additional issues they might want to consider.
- For doctors though, certainly one of the challenges is that medical information doubles at a very fast rate - and it is hard and time-consuming to keep on top of everything. As well, as a physician pointed out to last week, as patients live longer with more chronic illness, they also become much more medically complicated. I think that creates an even stronger responsibility on patients to be organized and informed themselves.
- @Ruth Knight-Bowes No question the well-informed patient is a relatively new concept for physicians. But there's no turning back on this. Physicians must be prepared to accept that patients are turning to all kinds of 3rd party sources of information.
- That's a good point, Dr. Goldman. To patients out there, how have your doctors responded when you arrived at appointments with information you found on the internet, or with a list of questions?
- @Erin Anderssen Erin, here's a link to what some VA hospitals are doing: www.ncbi.nlm.nih.gov
- Here's another link to what the VA is doing with decision support to reduce diagnostic errors: www.ncbi.nlm.nih.gov
- Hello all - I was the heart attack survivor mentioned in Erin's piece. Since then, I have a special interest in the subject of diagnosis - and misdiagnosis - particularly in women's heart disease. We know, for example, that women heart patients are underdiagnosed compared to their male counterparts, and then undertreated even when appropriately diagnosed. I'm so glad that Erin included both Dr. Croskerry and Dr. Groopman's perspectives in this article; "How Doctors Think" should be required reading for med students. Have you read it, Dr. G?
- Dr. Goldman, I have also heard from readers who said that when they felt they couldn't get their family doctor to run a test, or address their concerns, they went to emergency and refused to leave until the tests were run. (We had an example in the story.) Are you seeing this more often in your ER shifts - or anecdotally?
- @Erin Anderssen Erin, don't want to lose your point that with medical knowledge doubling rapidly, an MD's training can get out of date quite quickly. Right now, I think the continuing ed model of refresher courses isn't working. We need a more comprehensive re-education in mid-career.
- @Erin Anderssen I'm definitely seeing more patients demanding that tests be done. There's a fallacy out there that doctors are motivated to save the system money by not doing tests. I don't believe most doctors feel that sense of fiscal responsibility. What I would say is that as the provinces try to save $, they will probably put decision support into test ordering with rules that forbid tests being done if there's no support for running them.
- @Erin Anderssen A couple years ago, I read Dr. Scott Haig‘s Time magazine essay called ‘When The Patient Is A Googler’. It was a scathingly arrogant attack, describing his Googling patients as “suspicious and distrustful, their pressured sentences bursting with misused, mispronounced words and half-baked ideas.” So that's what ONE doctor thinks about those of us who find information on the internet . . . . ;-)
- I would like to suggest that patients seeing their doctor or one in the emergency/outpatients department be given a questionnaire that asks them to describe what they think their problem is. There is so much time spent waiting, and if the patient is not clear and articulate at the time they are seen, either in triage or by anyone that first sees the patient, the patient and the health team members are not getting information they need. I would like to see that it is mandatory in such settings that an advocate be available to assist all patients in this regard.
- @Carolyn Thomas I'm glad you survived, Carolyn! I have not only read both Groopman's and Croskerry's books, I've had both on White Coat Black Art. ER personnel are particularly vulnerable to cognitive errors because we don
' - @Carolyn Thomas ...because we don't know our patients and because of distraction and time pressure. We MUST know our cognitive biases to make fewer mistakes.
- Dr. Goldman, do you think that a change is required in medical school curriculum in order to bring more attention to this issue and hopefully lower the number of preventable adverse events? Or do you think a cultural change would be more effective (such as not looking down on a resident who asks for help at the end of a 24 hour shift)?
- Hi Liz, I think your point about patients organizing their thoughts while waiting is an excellent one - even if it means making sure they know the timeline of their symptoms, and have the names of any medications (and their doses) written down. Many of us have been to the doctor enough to know the kind of questions we can expect.
- Hi Dr. Goldman, I'm currently an applying for medical school and I'm wondering how to approach this subject if it comes up in an interview. I remember reading that physicians should never say 'they made a mistake', but I think it's important to emphasize that as an aspiring physician, I have to try my best but recognize that, like everyone else, I am human. I am worried that the application panel would not look too favorably on this view, however.
- @liz That's an interesting idea. It won't work though for patients who are unconscious, intoxicated, or can't articulate their symptoms. But it could save time for the rest.
- I also really appreciated Dr. Croskerry's point about patients who waste time complaining about how long they waited. That seems like something better addressed to your MP.
- I wish we had a forum to talk to med school students - let them learn from those of us that have been misdiagnosed or spent years to get diagnosed.
- @Meghna D Yes, we need to change the culture of medicine to address errors - not just in med school but well beyond. I did a TEDtalk in which I said the culture of medicine feels unhealthy shame about errors. I believe that sort of shame makes it difficulty for them to confront their own obvious human frailty...
(Here's a link to that talk: www.youtube.com) - Dr. Goldman: Obviously an unconscious patient would get a pass. :) However, any time I have gone to emergency, the dozens of people in the waiting room (especially parents with their kids) would clearly be able to do this.
- @Citygirl Today, MDs are supposed to admit they've made a mistake. The wise MD knows how to say "I don't know" to a question instead of speculating. Apology legislation is an attempt to make it easier for hospitals and MDs to admit mistakes. It has helped curb lawsuits in the US.
- @Dr. Brian Goldman - You are so right about ER pressures, distractions and workload. Because I'd worked in my hospital for 10 years myself before my heart attack, and because I KNEW this, I made the (very foolish) decision NOT to go to the E.R. at 2 a.m. despite increasingly horrific symptoms - but instead waited until "after shift change" at 7:30 a.m. when I knew the staff would be "fresh". Craziness....
- Hi Ruth, I know Ovarian Cancer canada has organized a program like this. Tara Jacklin, the young woman featured in our story, will be speaking at McMaster about her case. But I think attendance is voluntary.
- @Erin Anderssen No question we don't get enough history from patients :).
- Dr. Goldman: You are right. If a patient is too ill or not concious and they don't have an advocate who know their problem they could not speculate that drugs are the culprit. Liz
- Given recent exposes by the Fifth Estate and on PBS regarding so-called shaken baby syndrome, why is the pediatric profession in mass denial? Why are there still ongoing misdiagnoses where parents who have premature babies with sub-dural bleeds and subsequent rebleeds at 2 or three months of age and are accused of violently shaking their baby when there are no signs of brain stem or other cercical and spinal injury?
- @Carolyn Thomas But are you risking a sleep deprived RN and MD at 2 am? That's the dilemma. But no question: ifyou have chest pain or think you're having a heart attack, go to the ER right away!!!
- @Erin Anderssen It's well documented that women with ovarian cancer have waited months and even years before a correct diagnosis was made - with tragic consequences.
- @Citygirl forgot to address your question. My short answer: be honest. That's the only way to be.
- Nfrailway: My sense is that the high-profile cases involving pathologist Charles Smith has created more care around making this diagnosis, but it is not a subject I have specifically covered.
