Friday, December 21, 2018
Tuesday, November 27, 2018
Danger at Your Doctors Office
In 1999, Susan Sheridans husband, Pat, went in for surgery to remove a tumor in his neck. After the surgery, the neurosurgeon gave the Eagle, Idaho, couple great news: The mass was benign—a fact the neurosurgeon confirmed after looking at the pathology report two weeks later.
“Little did we know that the pathologist had been conducting ongoing stains on the tumor and had released a final pathology report 21 days after the surgery,” says Susan, now 48. “It said ‘malignant sarcoma.” Cancer. But the Sheridans never got this critical update because it was mistakenly filed away at Pats doctors office without the physician or patient ever seeing it.
Within six months, Pats cancer had spread dramatically; he died of it in 2002, at the age of 45, leaving behind two school-age children. Had Pats malignancy been aggressively treated after that first surgery, he would likely be alive today. “There was no system in place to make sure a life-or-death document was read,” explains Susan, who discovered the error after requesting Pats medical records.
The mistake that cost Pat Sheridan his life took just seconds. Even if most errors dont have such tragic consequences, the circumstances that prompt them are everywhere—and screwups happen often. In fact, 95% of physicians report having witnessed a serious medical mistake, and 56% say theyve personally been involved in a serious preventable error, says Sanjaya Kumar, MD, author of Fatal Care: Survive in the U.S. Health System. And these mistakes kill. “To Err is Human: Building a Safer Health System,” the Institute of Medicines 1999 seminal report that first brought to light the problem of medical mistakes, noted that up to 98,000 preventable deaths happen each year in hospitals. But deaths in other settings, including doctors offices, were about three times that.
Next Page: Why the doctor’s office is so risky
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Why the doctor’s office is so risky
Simply put, “Medicine is more complicated today. Its a lot more daunting,” says Pamela Gallin, MD, author of How to Survive Your Doctors Care: Get the Right Diagnosis, the Right Treatment, and the Right Experts for You. “There are so many more treatment choices, often for diseases that once couldnt be treated. There are more moving parts.” Here, four key factors that are making a trip to the doc more dangerous than ever.
Appointments are shorter
The average doctors visit lasts seven minutes. Blink-and-youll-miss-it appointments conspire against safe care, says Dr. Gallin, who is also a clinical professor at New York Presbyterian–Columbia University Medical Center in New York City. She likens medical care today to the famous I Love Lucy episode in which Lucy cant keep up with the chocolates coming down the candy-factory conveyor belt. “The system has sped everybody up, and everybodys multitasking more. If I have more time to think about a patient or a diagnosis, Im going to be more attentive,” she says. “When doctors are forced to go faster, their judgments have to be formulated more quickly.” That pressure-cooker environment makes every decision ripe for error.
There arent enough primary-care physicians
By 2025, we will be down 200,000 MDs. Fewer students want to go into family medicine, internal medicine, and pediatrics—the areas in need of those workhorse docs who provide the great majority of year-in, year-out care. “Family care has become one of those jobs Americans wont do, like picking grapes,” says Phil Miller, vice president of communications at Merritt Hawkins and Associates, the countrys largest physician-recruiting firm. If youve tried to get a last-minute appointment (or, in many places, any appointment) you know that the MD shortage has already arrived in some parts of the country. This means you may not be able to choose your doctor so easily, which might result in your inability to pick the safest ones.
People are playing “musical doctors”
Maybe youre a patient in a practice with several doctors who rotate in and out of your appointments; half of all physicians today are in these plus-size practices (with three or more MDs). Maybe youve moved around a lot. Or maybe youre seeing a revolving door of specialists. Whatever the reason, “you rarely go to just one doctor,” Dr. Gallin says. “The system mandates that you go to an internist to check your blood, a radiologist for a mammogram, a gynecologist for your Pap smear, and a pathologist is reading your Pap smear. Youre up to four doctors and nothing is wrong with you. Four people—any one of whom can mess up.”
A critical test result may go missing or not get to the office in time for a patient to schedule a follow-up appointment, or different specialists could be prescribing drugs that cause dangerous interactions. Whats more, safety experts know that any transition in care—as happens when a patient sees different doctors in a medical group—raises the risk for experiencing a slipup.
Safety isnt on the radar of many practices
Safety is becoming more and more of a buzzword in hospitals. But doctors in stand-alone practices are on their own to educate themselves about medical errors and put in place protections (including costly technology) that could safeguard patients. “Theres also a lack of feedback—an error can occur, like a missed diagnosis, and the [physician] who missed it may never know,” says Tejal Gandhi, MD, executive director of quality and safety at Brigham and Womens Hospital in Boston. “The patient may be [correctly] diagnosed a year later by a different doctor,” but this means the stand-alone doctor may not even grasp the size of the problem in her own practice.
Next Page: What goes wrong
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Misdiagnosis
Misdiagnoses—and missed diagnoses—are perhaps the most-feared of all the kinds of doctor errors. And for good reason: “In about half of cases where a diagnosis is never made or delayed significantly, the result is real harm to the patient,” says Jerome Groopman, MD, author of How Doctors Think and the Dina and Raphael Recanati chair of medicine at Harvard Medical School.
How do well-trained MDs blow the call?
There are three main thinking traps physicians fall into, leading them to the wrong diagnosis, Dr. Groopman explains. The first happens when “the doctor makes a snap judgment by seizing on the first symptom or finding.” The second: sticking only to the diagnosis foremost in her mind. For instance, when a doctor has just seen 15 consecutive flu cases, “thats whats most likely to come to mind when he sees a 16th person,” Dr. Groopman says, even though patient number 16 may have something else. The last type has to do with negative stereotypes. “For example, if a woman in the middle of menopause has hot flashes and headaches and feels jittery, her doctor may attribute any of her complaints to menopause,” he says.
These assumptions can add up to a lot of wrong calls: About 15% to 20% of all diagnoses are missed or flat-out incorrect. One study of settled malpractice claims found that 59% of outpatient claims were for a diagnostic screwup. The most common errors? Incorrect reading of a test result; wrong or inadequate follow-up care; and missed or delayed cancer diagnosis. Breast cancer accounted for about 42% of missed cancer cases.
Thats what happened to Maureen Thiel. The 40-year-old Pennsylvania mother of two first found a lump in her left breast during a self-exam in late 1994. She followed up immediately with a mammogram and ultrasound and was told she had fibrocystic breasts. Although the lump didnt wax and wane, as is usually the case with this condition, her initial doctor and two subsequent ones she saw failed to advise her to get a biopsy. By February 1997, Maureen had found a new lump—this time under her arm. She then saw a different doctor, who ordered not only a mammogram and ultrasound but a biopsy; the tests turned up stage III metastatic breast cancer. “She was positive [for cancer] in all 47 lymph nodes,” Maureens husband, William, says. “She lived 15 months.”
Communication breakdown
Many errors stem from a communication lapse. “These errors go to everything,” says Nancy C. Elder, MD, an associate professor of family medicine at the University of Cincinnati and one of the few researchers to study mistakes in doctors offices. In a 2004 study of 75 errors reported anonymously by family physicians, 47 were triggered by miscommunication.
So what is a communication error, exactly? Its the rushed doctor who doesnt listen and brushes off your concerns—or even your symptoms or pain; the lost medical record or referral that delays diagnosis or treatment; the rude office manager or nurse who makes it impossible to get information or an appointment when its really needed; or the phone that never rings with word about that lab result youve been losing sleep over. “Anytime you undergo a test, you should always get the result back,” Dr. Elder says. “‘Well call you if anything is bad isnt an acceptable response.”
Medication mistakes
If you take even one prescription med, youre at risk for an error. Your doctor could give you the wrong drug, wrong dose, wrong type (pill versus liquid), wrong timing (morning versus evening)—or you could even be the wrong person (i.e., you dont need the drug). And the more meds youre on, the more likely it is youll experience dangerous interactions. (A side effect shouldnt be confused with an error, though.)
As tempting as it may be, bypass free drug samples, advises Allen J. Vaida, PharmD, executive vice president of the Institute for Safe Medication Practices, in Horsham, Pa. Theres a debate about whether physicians should dispense samples in the first place, because theres no way for pharmacists and other providers to know youre on that drug. “Sometimes labeling is really inadequate,” he adds, citing an example of an arthritis-pain-med sample that came in a blister pack of three capsules: “The box said to take 200 milligrams, but it never said that each capsule was 200 milligrams, so people were taking all three.”
Drugs can expire without a doctor or patient realizing it, too. “Pharmaceutical reps leave samples in the doctors drug cabinet—in front of their competitors,” Vaida explains. That means some drugs languish on the shelf for months before they make it to you. Finally, when you get a drug off the record, youre less likely to hear about a recall because theres no log of who got what sample and lot number.
Next Page: Can test results be trusted?
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Testing blunders
Chances are good that, at least once, youve had some sort of medical test and then waited…and waited…and waited…to get your result back. Maybe the doctors office finally got in touch (after youd driven yourself mad with worry), or maybe they never did. If you never got the result—good or bad—thats an error. If you got a result saying you had a disease or condition when you didnt, or that you didnt have a disease when you really did, or that you had a disease but it turned out to be another disease, those are testing mistakes too, as is a lost lab result and mixing up your specimen with someone elses. When you consider that the average family physician sees about 100 patients a week and orders tests for 39 of those, its not hard to imagine the opportunity for blunders.
In 2006 Darrie Eason, a then-33-year-old single mother from Long Island, N.Y., was one of those unlucky few. Shed gotten the news every woman dreads: She had breast cancer, and it was aggressive. Her doctor recommended a double mastectomy, so Eason went for a second opinion and brought along the test results her first doctor had used to make his recommendation. The second doctor gave her the same advice, and she decided to have both breasts removed. “I was told I had lobular breast cancer, which everyone said would come back,” Eason told the Today show last fall. But after her double mastectomy, she learned she had never had cancer: The lab had mixed up her biopsy results with those of another woman.
What goes wrong most often?
A 2008 study found that many mistakes happened in the doing of the test—it wasnt done, the specimen was lost or improperly stored, or the wrong test was performed or scheduled. Most common, though, were glitches in getting test results to the doctor in a timely way (or at all). In fact, 39% of the time, one mistake led to another, and 60% of the errors took place in an MDs office, not in a lab.
And 1 out of 10 times, the mistakes in the study resulted in pain and suffering, as in the tragic mix-up that cost Eason her healthy breasts. A doctor can also fail to get enough of a tissue, blood, or urine sample or take a sample from the wrong place, perhaps giving a false-negative result when disease is present, explains David S. Wilkinson, MD, PhD, professor and chair of the department of pathology at Virginia Commonwealth University, in Richmond, Va., and chair of the quality-practice committee for the College of American Pathologists, which accredits U.S. and foreign labs. Or, he adds, a pathologist can simply write the wrong thing in a report. “It can be a subtle error, writing ‘malignant cells seen instead of ‘no malignant cells seen.”
It gets even dicier when a test is complicated to interpret. Tests that require analyzing a tissue sample are particularly prone to error, because theres often no clear-cut interpretation. “Looking at a biopsy and deciding if its cancer and what kind is not as precise as measuring glucose in a test tube. Even knowledgeable, conscientious, well-trained people may have differences of opinion,” Dr. Wilkinson says. Hence the need for the all-important second (or third) opinion to interpret pathology results for biopsies.
Next Page: Take action now
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Take action now
There are simple steps you can take to guard against mistakes. First, choose your physician very carefully. Be sure shes affiliated with a top hospital. Remember: Youre not just picking an MD for an annual checkup; you may one day need her for something more serious. “A doctor affiliated with a top-notch hospital extends to you the high-quality care of all the specialists and support staff she knows there,” Dr. Gallin says.
Once youve found an MD you trust, stay loyal. Jumping from physician to physician—or popping in and out of in-store and after-hours clinics ups your odds that a key piece of information, like a test result or potential drug interaction, will slip through the cracks. If youre seeing several specialists, consider it your job to make sure all parts of your medical story are filled in on all your records, kept updated, and, most important, consolidated with all records from your different care providers. Keep your own copy, too.
It also helps to be a good (read: organized) patient. Before you land in an exam room, “know all the details of your family history and how long youve had symptoms,” Dr. Gandhi says. Also bring a list of all medications and supplements youre taking, because this can avert a medication disaster.
The time for a passive, blinders-on approach to our medical care has passed. “A lot of people are worried about alienating or insulting their doctor by asking questions—when I was a patient I felt the same way—but a good doctor welcomes that kind of input and questioning,” Harvards Dr. Groopman says.
This approach can go a long way toward protecting you, Susan Sheridan believes. In addition to losing her husband to a delayed cancer diagnosis, her son, Cal, now 13, was the victim of lack of treatment for too-high bilirubin levels as a newborn, which resulted in kernicterus, or brain damage from severe jaundice.
“Dont be afraid to be demanding,” says Sheridan, who now works as a patient-safety advocate. “Dont be afraid to ask too many questions. Women are the number-one health-care purchasers for our families, so we can be very influential in safety. And maybe were better wired to be, because were mothers, were wives, were caretakers. We have a huge opportunity to keep ourselves and our families safer.”