NY Times – Why doctors get it wrong:
But we still could be doing a lot better. Under the current medical system, doctors, nurses, lab technicians and hospital executives are not actually paid to come up with the right diagnosis. They are paid to perform tests and to do surgery and to dispense drugs.There is no bonus for curing someone and no penalty for failing, except when the mistakes rise to the level of malpractice. So even though doctors can have the best intentions, they have little economic incentive to spend time double-checking their instincts, and hospitals have little incentive to give them the tools to do so.
“You get what you pay for,” Mark B. McClellan, who runs Medicare and Medicaid, told me. “And we ought to be paying for better quality.”
Dr. RW begs to differ:
Although the Times article suggests that pay for performance and penalties for errors might solve the “crisis” the data suggest otherwise. Studies on Pay for Performance to date have failed to demonstrate improved quality. A spate of articles analyzing medical error indicates that promotion of a culture of blame by penalizing doctors for honest mistakes is counter productive.The JAMA perspective is more nuanced: “However, it remains unclear to what extent clinically missed diagnoses represent errors per se, rather than acceptable limits of antemortem diagnosis in the face of atypical clinical presentations. In fact, because the vast majority of autopsy studies come from teaching hospitals, published autopsy series may be enriched for atypical cases.”
Related posts:
- Medical errors: Impact on physicians
- Pay for performance unintended consequences
- Pay for performance follies
- Is reducing medical errors similar to improving transportation safety?
- Does pay-for-performance work, and will it improve health care quality or patient outcomes?
- Working harder won’t reduce medical errors
- Op-ed: Medicare’s mistake
{ 75 comments }
Paying doctors for cures and accurate diagnosis is the dumbest idea that ever came to medicine. What are we to do with illnesses that are chronic and have no cure, like lupus or hypertension.
If doctors are paid by outcome, patients that have diseases with poor prognoses, like liver cancer or spinal injuries, will find themselves unable to find a doctor.
To take an example, some diabetics are very easy to manage. Others are murder, and the difference may have nothing to do with the doctor or the patient, it is just that physiologically some people have more resistent diabetes than others. A patient who has a poor outcome may have been very well managed; some patients do well despite poor treatment.
The Times needs to jump in the lake.
Doctors have to get with new market realities. If there are financial incentives for finding successful treatments, to use the commenter’s above example, for treating “resistent diabetes,” won’t we improve the chances of finding successful treatments?
Is it “fair” that less successful doctors will get paid less that more successful? Maybe. Welcome to capitalism.
If its capitalism you want, then get rid of all government involvement in healthcare.
When the govt, via Medicare, controls half of all healthcare dollars spent in the United States, then referring to healthcare as a “free market” or “capitalistic economy” is a joke
I’ve got no problem with the free market. Lets get rid of all this govt intervention and start from square one again.
Prior to anesthesia I was a pathology resident and examined the methodology of the studies that evaluated the so called diagnostic error rate detected post-mortem.
The impact of the error rate is not so dramatic as it may seem. If the patient has cancer, and dies from the bleeding metastasis in the brain, but had a thromboembolus in the leg that was undiagnosed during life did it matter. It still counts in the tally of undiagnosed condition, but mattered not for the dead patient. That it was ultimately recognized was important because it allows changes to future processes that are now ingrained in hospital care to prophylax for thromboembolus, to suspect it during life so that greater moniting can occur and treatment will begin. Sometimes that treatment leads to the avoidance of a thromboembolus migrating to the lungs to kill the patient; sometimes that treatment causes excessive bleeding elsewhere in the body and the patient dies anyway.
The point is, may post-mortem ‘missed’ diagnoses don’t mean much.
That the rate has held apparently steady at 20% also means little, as there is no comparison between the types of diagnoses missed then and now. It is even quite possible that the old post-mortem exams would be judged by the modern post as having a less than stellar rate of correct diagnosis.
Finally, because the rate of post-mortem exams is now so low, only cases with some uncertainty are subject to this final check. The application of the post-mortem exam is not a randomly assigned process, but is selected by the presence of strong clinical uncertainty on the part of physicians and/or family. In the old days when virtually every death had an autopsy there was little selection bias to artificially boost the % uncertainty.
Why do all these discussions end up as us against them,capitalism vs national health care rants? The original topic was errors in clinical diagnosis.
When all patients arrive with all the information and physical signs necessary to make a correct diagnosis,then we can worry more about absolute error rates. The hard part is defining and correcting the rate of harmful errors
Patients are not widgets.Everything doesn’t change or break in the same way every time.They often have multiple comorbidities that complicate making a totally accurate diagnosis.
I suspect 90+% of us want to make the correct diagnosis and treat patients successfully because its what we went into medicine to do.For the plumbers and money grubbers,I guess financial incentives will help.For the rest of us,I ‘ve been impressed with the results of continuing quality improvement based medical education.
As a patient, I’ve had doctors who covered the spectrum from excellent to awful. It sure would be nice to reward the great ones. Here are some examples of the good and bad:
Doc A told me twice that nothing could be done for my condition, after I had heard of a helpful drug. I paid out of pocket for a specialist to examine me, and he promptly told me yes indeed, the drug would work wonders (and it did). I later found out Doc A was being paid a bonus by the insurance company to hold down costs by denying prescriptions.
Doc B thought the elephant on my chest was a heart attack, but tests ruled that out. He never could figure out the problem, which would go away when we went on vacation in Colorado, but come back the day we returned home.
We later switched to Doc C who immediately said I had asthma induced by GERD, gave me a prescription, and that was the end of the problem. (It went away while I was on vacation because I was relaxed, and resumed when I returned to the tension at work.)
“Doc B thought the elephant on my chest was a heart attack,”
Doc B didn’t think the elephant was a heart attack, he had to rule that out because it was the most likely diagnosis you could have that if he missed it, you could sue him. Once he ruled it out, assuming you’re not John Ritter with some rare disease, he could care less what you had because you’re no longer a possible legal liability.
No doubt, the story is not without hype or inaccuracies.
But let’s not miss the forest behind the trees. Fighting the public’s perception that there is room for improvement in health care quality is a losing proposition, both politically and economically.
Here are the details: P4P & Quality: NYT Rages On. AMA Goes Along.
Why do you think medication to treat GERD is a placebo medication. Do you think GERD is an imaginary illness? If you do and you’re a Doc. you need to spend some time doing EGDs…
Obviously you don’t know that GERD can cause esophageal spasms, ulcers, erosions, strictures, Barrett’s esophagus and even EC…Many people have mid chest area pains from GERD.
“Obviously you don’t know that GERD can cause esophageal spasms, ulcers, erosions, strictures, Barrett’s esophagus and even EC…Many people have mid chest area pains from GERD.”
But nobody wins the lottery from missed GERD, so who the hell cares? Welcome to American Medicine.
I hope to hell you aren’t a real Doctor! So, your saying that if a person has an EGD, maybe 24 hr. ph studies and GERD gets missed, and biopsies maybe were taken in the wrong area (which happens quite regularly) doesn’t pick up any Barrett’s,dysplasia, or cancer that there couldn’t possibly be a lottery when that person is later seeking a second opinion and finds out he has esophageal adenocarcinoma? You do realize that EC caused from Barrett’s caused from GERD only has a 5-10% survival rate.
Now, can you tell us what the fastest growing cancer (by incidence) is in the united states?
I think you might be one of those Drs. in the middle of a lawsuit and your just p***** at the world..If not, then you are a professional rattlesnake.
“once he ruled that out, he could case less what you had because your no longer a possible legal liability.”
Why did you become a Dr.? You HATE patients. I’m starting to think you might be a malpractice attorney trying to drum up business.
You know, get online ,go to some of the most popular medical blogs on the web, try to turn everyone against their doctors.
Atleast that would make some sort of sick sense. To imagine you in the role of Physician and ever gaining any trust or respect from your patients is not possible.
My problem with the NYT article:
The reporter, with the advantage of hindsight, path reports, a reserach department, fact checkers and editors still makes a misdiagnosis – calling necrotizing fascitis a “flesh-eating virus”. Will the reporter make any less money becuase of that?
And thanks to the poster who pigeon-holes his or her doctors into “good” and “bad” on the basis of a single encounter – it affirms my decision to leave practice.
To the posters above regarding missed esopahgeal adenocarcinoma: which diagnosis creates infinitely more lawsuits and cash generation for attorney’s: Missed MI or Missed Esophageal adenocarcinoma? C’mon!!
folks…I never said that gerd isn’t real or wouldn’t lead to a lawsuit…what i am saying is a primary care physician has to do things in a certain order:
for you patients out there:
evaluation of chest pain=
cardiology workup and chest xray simultaneously, then gi workup including endoscopy, and keep referring to different specialists until the patient does not come back or the symptom goes away.
Why you would pay out of pocket to see a Gatroenterologist is beyond me…
“Why you would pay out of pocket to see a Gatroenterologist is beyond me…”
He’s probably an HMO patient and his PCP would not approve a referral. Just a guess.
“Which diagnosis creates more lawsuits and more money for lawyer’s, missed MI or esophageal adenocarcinoma”?
So, we are right back to the important issues,”YOU”, the doc.
What you’re saying is that when we come to,you we aren’t people who need medical care. We need only have certain things ruled out. Things that are most important to YOUR health…When you have done that then the rest doesn’t matter? Who the hell cares if we get well or not as long as your health isn’t affected by our visit?
It’s almost funny that when we are ill and come to you for help, your the only one thinking about Lawyers and lawsuits. For the vast majority of us it never enters our mind. Thanks for clearing that up. I appreciate your honesty!
a pcp would always approve the referral…it spreads the liability to other specialists.
There is no downside to giving a referral…so that doesn’t make sense.
anonymous 1:32 – First of all I doubt that it would “not enter your mind” to sue if a doctor misdiagnosed cardiac disease and called it gerd/asthma/whatever. Secondly, even if you didn’t want to sue, once you died your wife/sister/daughter/grandson/whoever would more than likely sue…now you understand?
“a pcp would always approve the referral…”
Hey stupido, do we have to educate you about HMO’s? Those docs won’t refer you to a specialist just like that. Where have you been this past 20 years?
I cannot believe how full of rage one of these guys is. I receive some small pleasure because I feel a bit misused by the system, but I’m nowhere near that level of bitterness. The reason that guy is so frustrated is likely because he is paying on a $100,000 student loan debt and he hates the job he can’t leave. Even if he wanted to be a plumber or a newspaper columnist, or whatever, he couldn’t do it because those things don’t generate an income large enough to pay off that debt. I feel for you my friend, but you’ve got to get some help for yourself.
b
anon, 1:23…No, your the one who doesn’t understand…
My family has lived through this nightmare that you describe..In the exact way that you describe it. My father was diagnosed with a hiatal hernia, this was in the 80s. He was diagnosed symptomatically only. There were no tests ordered and no tests done. He was put on Tagamet (that was the prescribed drug of choice at the time.) By 1989 his chest area pains were becomming more severe and much more painful. I can recall atleast 3 trips to the ER where they would do an EKG and blood work and the diagnosis was always the same…..Reflux and hiatal hernia! Increase your tagamet…In Nov. 1990 I walked in their house and looked out the kitchen window and my Dad was lying in the middle of the back yard with mother trying to get him up. He couldn’t stand because of being dizzy and vomitting.
EVEN THEN….when the rescue got him to the ER the results of EKG and bloodwork did not indicate coronary problems. They admitted him overnight for observation and told us to come back and pick him up in the morning as they were sure it was NOTHING, other than his HH..At 5:00am the next morning I received a call to come to the hosp. the message was that he was now on morphine, his pulse and BP were dropping and the cardiologist was with him now.
When we arrived he was full force in the middle of an MI…The Dr. told me to call my brothers home from Fla. and my sister from NJ as he most likely would not survive.
He did survive and the next day, he was transfered to a larger hosp. for a heart cath. (the first one in all these years of symptoms)..The outcome of that was that the clot that hit his heart was so large that it destroyed the bottom half of the R Ventricle. We were also told this was not his first heart attack and that he had to have been suffering from severe angina for years. This was told to us by the heart Dr. that performed the Cath. He was the section head of coronary surgery at this hosp. The next evening my Father passed away from coronary rupture..
Now to the only thing that matters to you..I have 3 siblings and at that time we still had our Mother, my Dad had 9 siblings still living and NOONE considered going to an attorney. It wasn’t that we were all stupid and didn’t realize that we coudl have…We knew!….It wasn’t important…
So why not get off your high horse and put just a bit of faith in the majority of your patients. Your attitude makes people want to sue you..If you accuse someone of something long enough most likely you will be proven right…
The above story wouldn’t happen today. In the ER, we’re so busy we don’t have time to tell a patient their chest pain is a hiatial hernia or GERD. WE assume it’s cardiac and treat them as if it’s cardiac. I’ll never be able to diagnose esophageal carcinoma in the ED (one patient every ten minutes, are you kidding) but I may admit the chest pain patient to a hospitalist who will. As to Primary care physicians, it looks like the above patient didn’t have one (all the above misdiagnoses were in the ER) Neither do most of my patients, leaving the onus (and unfortunately the liabilty) on me. Thus chest pain is cardiac (or a PE) till proven otherwise
If you want to vent about your professional frustrations, have at it.
But skip the name calling, ‘K? “Stupido,” “lunatic,” “a crazy person like you,” etc. It’s unseemly for a bunch of people who belong to the so-called caring profession. And it does not inspire good feelings among the laypeople who visit this blog in search of insight and education.
1. I am a physician and I deal with every insurance imaginable…I never had a problem referring to a GI.
2. The person above who said they didn’t sue is the exception…but he admits that he knew he could…which means that he thought about it…
Even though you didn’t sue…I don’t want to be in a position where you could even potentially sue me or screw me…so anyone like you or your father or mother or whatever gets the full $1,000,000 workup!
Some of you (or one of you) are the rudest most arrogant Physicians I have ever seen. Maybe you are just blowing smoke because of this setting and you want to look like a real “badass” to the other Physicians. I don’t really care. I can only thank God that I have “NORMAL” compassionate Drs.
There is one of you that if you practice and treat your patients the way it appears you, do then I think you have plenty of reason to be worried about lawsuits, they will happen to you.
You need to see a shrink and the sooner the better, for you and for your patients..
you’ve got to be kidding if you think that a physician is going to skip the cardiac workup because he is relying on your mercy and civility in not suing him…
I don’t think he/she is talking about your cardiac work-ups. It seems that your unstable and hate patients and that most likely you aren’t fit to be ordering tests of any kind for any reason. You sound like the same guy that was telling us (the other day) about the medical group he practices in where part of the drs. were on anti-psychotics.
The person above who said they didn’t sue is the exception…but he admits that he knew he could…which means that he thought about it…
I am curious. What is the percentage of people who sue? You say that the guy who didn’t sue it is an exception, but I’ll be curious to see actual statistics of what percentage of people who were harmed (or who could in their ignorance perceive to have been harmed) actually sue? Not counting obvious negligence cases like removing wrong leg or forgetting instruments inside the patient.
I don’t know much about particular conditions that were described here. I am just curious on this point.
We could probably estimate the number of lawsuits a year vs the number of patients, but one needs to figure out the number of mistakes. Anybody has done this math?
Does the author of the quote above have data to substantiate his/her statement?
The physician that is being criticized is correct, but could have worked a little on his delivery. The fact of the matter is that life-threatening problems such as MI must be ruled out first. In an ER, our most frequent diagnosis of chest pain is “chest pain, unknown cause.” Meaning we have ruled out life-threatening causes and, due to the fact that we are trained and designed FOR EMERGENCIES, we leave it at that. A primary doctor, then, has to sort it out. With the benefit of our ED evaluation, the primary doctor can comfortably suggest a diagnosis and start therapy without having to worry about missed MI.
The patient who rates his doctor based on those encounters may not completely understand what happened to him. This is a failure on our part to communicate more effectively I suppose.
My patients are generally satisfied with the care I give in the ER, but their satisfaction has nothing to do with the quality of care they received. For example, if the patient above had actually been suffering from acute MI, then doctor #2 might have been his favorite doctor. Patient’s perceptions are a very unreliable gauge of quality of care. When I listen, establish repoire, and act kind, my patients are happier. When I suggest possible causes and give them the impression that their symptoms are concerning and interesting, and come up with a couple of diagnoses, they feel better. (For example, I recently received a glowing thank you letter for listening to a lady talk about her chronic foot pain and suggesting that maybe it was reflex sympathetic dystrophy and that she ought to see a neurologist–she was grateful that I took her seriously. I sincerely doubt she has any real disease, and the neurologist isn’t going to be very happy with me, but people want someone to listen and give answers). But these happy patients are not getting better care. Similarly, when I exclude life-threatening illnesses in lots of people, and admit that I don’t yet have an answer, I am providing good care, but am unlikely to be considered popular. Patients have become consumers and don’t seem to understand that sometimes no answer is a good answer, or that sometimes the best treatment is no treatment.
I see a couple of serious problems with the article. A 20% missed diagnosis rate (when, as already mentioned, autopsies are mainly performed on puzzing cases) is impressively low. Unlike airplanes, we know very little about the human body. We are always learning more, and it is a fascinating and challenging process. Unlike airplanes, we didn’t build the human body. Unlike airplanes, every body is different.
A second problem is the reliance on hindsight. In general, an atypical presentation of a common problem is far more likely than a typical presentation of an uncommon problem. Thus, a child with apparent leukemia who also has brown spots, is far more likely to have leukemia and brown spots of no significance. Had the doctors waited to start chemotherapy until all such rare diagnoses were excluded, the child might have died, and this would have been considered a grave medical error. If doctors now start ruling out the most rare problems before starting any treatment, then costs will skyrocket even further, and bad outcomes will increase in frequency. It’s amazing the lack of any basic knowledge of statistics, even among writers of what is widely considered to be a good newspaper.
Patients’ unrealistic expecations, fostered by direct advertising, consumer culture and articles like this, increase the threat of liability. My first goal is always to prevent bad outcomes and exclude life-threatening disease. My second goal is to give the appearance of good care. These are frequently mutually exclusive and when they are in conflict, I choose the former.
“I don’t think he/she is talking about your cardiac work-ups. It seems that your unstable and hate patients and that most likely you aren’t fit to be ordering tests of any kind for any reason. You sound like the same guy that was telling us (the other day) about the medical group he practices in where part of the drs. were on anti-psychotics.”
You gotta love how people think they can rate physicians. I don’t know which is worse, that they think they can judge a physician based on one 10 minute visit or based on what he anonymously posts on a Web Blog site!
thanks for the help Bad Shift in explaining it to these idiots…I don’t have the patience to go through it like that…
I had approximately 75,000 patient encounters in the ER this past 15 years. A 20 percent missed diagnosis rate would equal to 15,000 wrong diagnoses and wrong patient management. Yet, I have not been sued this past 15 years. And I wasn’t fired either. Sure, I have missed a diagnosis or read an Xray film that the radiologist did not agree with my reading, but I didn’t miss 15,000 cases. The writer of the article needs better proof than an anecdote and selective autopsy finding. He needs to make use of the scientific method. If he submits this article to a peer reviewed scientific journal, it won’t pass.
” Yet, I have not been sued this past 15 years”
A No Hitter!!! Let the other ER docs on this site know you’re secret!
75,000 patients and not a single lawsuit? What state are you in? Do you admit more patients then your colleagues do? What patient population do you deal with? (wealthy, poor, lots of alcoholics?) Congrats!
you just jinxed yourself!
Well, I have been sued. I have not been sued this past 15 years, but I have been sued twice this past 20 years, during the first few years of my ER carreer.
Statistically you’re opposite the norm. Several studies have shown the more years of experience you have the MORE likely you are to get sued. I always thought the explanation was that more experienced MDs get more careless. Go figure.
You gotta love how people think they can rate physicians. I don’t know which is worse, that they think they can judge a physician based on one 10 minute visit or based on what he anonymously posts on a Web Blog site!
This goes both ways. Read posts from physicians about patients who post here. They constantly make assumptions based on 2-paragraph posts.
Interestingly, the logic of these conclusions – you are the type of person who waste doctor’s time, you are the type of person who goes to a doctor for every minor thing, often escapes me. Maybe it is my English.
Anon,4:11…You had stated that it looked like my father didn’t have a PCP..Yes, he did…He and my mother had the same Dr. for atleast 30 years at that time.
Their PCP was the one who initially diagnosed his hiatal hernia. However, he didn’t persue any tests to back up that diagnosis. In fact told him that he didn’t want him going to a larger town, (we didn’t have any GI Spec. locally at the time) for any tests because they would want to do surgery for this hernia and that it was a terrible surgery. We know now that it is not such a terrible surgery, many people have it done. Certainly the better option than having coronary rupture.
My Mother, Dad, and yes, even us, would tell them in the ER that he had a hiatal hernia. They do take a history and ask about prior chest pains so we would tell them what we knew. We did so because we were told he did have. We believed it, had no reason not too.
We didn’t blame any ER doctor when he passed away. Mostly we blamed ourselves for so easily excepting one Drs. diagnosis and not pressuring our Father to get a second opinion.
I’m very happy that all chest pains in the ER now result in a coronary workup but what exactly does that include? EKGs and blood work didn’t show this was happening.
anonymous 3:47, after admission ekg and bloodwork the patient is admitted to telemetry (heart monitoring) and a cardiologist is called to enter into the CYA gangbang…cardiac muscle enzymes are checked multiple times to make sure they are not going up because the first set of blood might miss it.ekg’s are repeated daily…
the cardiologist orders an echocardiogram to see if the heart has any structural abnormality or if the wall motion is not right and then a stress test is ordered either inpatient or outpatient depending on how much of a cowboy the cardiologist is…
that’s one of the pitfalls for doctors practicing in small towns there aren’t a lot of specialists to refer to to cover your ass…if you lived in philadlephia or la the pcp would have immediately referred you to a cardiologist, gi, etc…the pcp’s in small towns are as close to real doctors as you can get because they actually have to figure things out on there own…have to give them some respect for that…
In a less “CYA’ way to explain this to you, in an elderly man like your father, his blood tests and EKG would have probably been normal, he may have had a treadmill stress test and Echo (ultrasound of the heart) as an inpatient or maybe not. With a normal treadmill test and echo, an elderly patient with unexplained chest pain, he may get a nuclear stress test, or even a heart catheterization if the suspicion is high enough. I see patients in the ER all the time who think they know the cause of their pain (”My doctor told me I get Migraine Headaches”,(” My chest pain is GERD,) I usually ignore this and pursue my own diagnosis. One of the big mistakes docs make is to believe without question what is in the patient’s old record.
anonymous 4:43 brings up a point I have always wondered about…if patients know that thair chest pain is gerd or migraine…why do they come to the er for that? Sometimes I feel like its just so if they are wrong they have someone to sue…
Oh for god’s sake. You gripe when we can’t give a history and you gripe when we try to. And if you think anybody who’s feeling lousy looks forward to the condescension and rolling eyes from drs like you upon reporting to the ER, you’re nuts. If all they have is GERD or migraine, why are they in the ER? I thought you didn’t like us making our own diagnoses, doc. It means the patient has been TOLD that’s what wrong…but as with the poor man mentioned above, SOMETIMES YOU GOT IT WRONG and all we can do is keep showing up till we die or YOU FINALLY GET IT RIGHT. Shame on you.
anon 12:27…I guess you have a problem with reading comprehension…what I was asking is if the patient thinks they have gerd why do they come to the E.R.? A lot of times these patients come in and say ‘Its gerd’ or “It’s a migraine” like a previous poster said…I was contemplating why they come to the er when they think they have one of these non-acute illnesses…
Anon..10:38 and 4:43…Thank you for explaining this to me.
As for why “someone would show up at the ER if they think they have GERD?” In this case it was because the chest pains were so intense that we were having a problem figuring out how GERD could possibly be this painful… I also imagine that people get to the point (while having chest pains) that they get scared and want the reassurance from a professional that “Yes, this is your GERD or HH acting up.” Your not suggesting that we hide our medical history from the ER personnel when we go there are you?
anonymous 4:43 brings up a point I have always wondered about…if patients know that thair chest pain is gerd or migraine…why do they come to the er for that? Sometimes I feel like its just so if they are wrong they have someone to sue…
Here is a thought. Maybe because they are not sure and don’t want to end up dead if they are mistaken? OK maybe they are 90% sure or 80% sure that it is nothing? What would you recommend I do if I get chest pain… would you quantify how sure I should be that it is nothing before I decide I should go to the ER? For my future reference (yes, I read the flowcharts of symptoms, but they don’t quantify…)
when would I recommend you go to the er? I guess it depends…if it was you, every time you have chest pain…because you see like a litiginous sob; if it was my family member, I would try to figure out what it is and treat appropriately…
yeah, when you get the chest pain pull out that flowchart…you doofus….
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