By Evan Falchuk

An important study in the Journal of the American Medical Association finds that misdiagnosis is more common than you might think.  According to the study, almost 40% of patients who unexpectedly returned after an initial primary care visit had been misdiagnosed.  Almost 80% of the misdiagnoses were tied to problems in doctor-patient communication, and more than half of those problems had to do with things that were missed in the patient’s medical history.

The results of this study shouldn’t be surprising if you’re a regular reader here – they are another example of a system that isn’t working as well as it could for patients, and doctors.  Doctors – and the medical professionals who help them in their work – are the best educated and best trained than they have ever been.  They have more access to medical information and technology than at any time in our history.  And yet, U.S. government data show that the typical doctor visit involves 15 minutes or less with your doctor.  Medical records are kept in fragmented, uncoordinated ways.

Never before have the stakes of getting the right diagnosis been so high, and yet our system is set up in a way that makes it increasingly difficult for doctors to do the jobs they were trained to do.  Seeing 40 patients a day, using uncoordinated medical records systems, and trying to keep up with continual advances in medicine is an enormous challenge under the best of circumstances.  And these aren’t the best of circumstances.  As the study authors point out, the greatest underlying cause is the failure to properly put together the pieces of a patient’s medical condition- exactly the type of thing you’d expect from people making high stakes decisions with not enough time or information.

The findings of this and other research underscore how important it is for patients to be active participants in their care, and to use every resource at their disposal to make sure they are not one of these many who are misdiagnosed.  Ask questions, know your family (and personal) history, and make sure you keep asking questions until you’re satisfied you are comfortable with what you are being told.

By involving yourself as an engaged, active part of your own care, you have a chance to help your clinical team avoid overlooking important facts, to help them avoid unwarranted assumptions, and to help them make sure they make the best decisions for you, with you.

By Evan Falchuk

Do doctors really listen to their patients?  A provocative new book, When Doctors Don’t Listen, says it’s all too easy for doctors to rush through the decision-making process – causing misdiagnosis and needless suffering.

It doesn’t have to be this way.

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By Evan Falchuk

If you study misdiagnosis you realize how often patients get the wrong diagnosis.  But what do expert doctors think about how often it happens?  And what do they think can be done to address it?  We wanted to find out so we partnered with the National Coalition on Healthcare to conduct a landmark, nationwide survey.  We surveyed 400 cancer specialists from our Best Doctors database – and the findings were provocative.

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Do people and computers “think” alike?

Not yet.

The NY Times reports on how people and computers make a diagnosis.  It turns out there’s a doctor named Dr. Gurpreet Dhaliwal, who does a kind of medical high-wire act.  He comes up with accurate diagnoses on challenging cases – in real time in front of an audience.  Now, not every doctor can do what Dr. Dhaliwal does – but most can do something like it.

So, what is it that doctors are doing when coming up with a diagnosis?  And can a computer do it, too?

Many doctors have an “encyclopedic” knowledge of areas of medicine.  But knowledge isn’t the same thing as insight – the ability to put together diverse pieces of information in a way that reveals the connections between them.  A computer can be programmed with all of the medical information ever discovered, but without insight, it’s no more valuable than a book on a shelf.

Even with advances in computer “thinking,” this is where the trouble lies.  Studies find that for as common as misdiagnosis may be (it’s estimated to happen between 15%-28% of the time), a lack of knowledge is rarely the cause of these misdiagnoses.  Instead, the problem is usually a failure to put the pieces of the puzzle together in the right way.  It’s a failure of what scientists call “synthesis,” and what the rest of us might call “insight.”

So computerized tools do have a role to play, if what they can do is trigger the doctor’s natural ability to apply insight to a problem.  Tools that help doctors question their assumptions about a case would, based on the research, be highly valuable.  But too much of the current focus of healthcare information technology is on prodding doctors to make sure they keep a detailed record of the fact that they, for example, counseled a patient to stop smoking.  Instead, we should use the remarkable technology already available to do something far more valuable – help doctors do exactly what we really want them to do.

Think.

By Evan Falchuk

A fascinating study in the BMJ (paywalled – free version here) talks about a kind of misdiagnosis that isn’t widely recognized – failing to figure out exactly what it is the patient wants.  According to the authors, doctors too often guess at (or don’t think about) what the patient would want if they were as confident and well-informed as the doctor.  For example, one study found that doctors believe that 71% of patients with breast cancer rate keeping their breast as a top priority — while patients report that this is their top priority only 7% of the time.

It’s an important issue, and not just because we should want every patient to get the care most appropriate for them.  Research shows that as patients become better informed about their condition, they make different, and sometimes less costly, treatment choices.  A Canadian study found a reduction of heart surgery of more than 20% in patients who became more informed about their illness.

There is an important role for policymakers in building awareness among patients and doctors of this problem, and what to do about it.  Patients need to take an active, engaged role in their healthcare, and doctors need to recognize how important this is to the quality of care they deliver. Errors in diagnosing a patient’s preference

…lead to inaccurate assessments of wants and needs….Evidence from trials shows that engaged patients consume less healthcare. More work is needed to understand the magnitude of this potential benefit, but it is tantalising to consider that budget challenged health systems around the world could simultaneously give patients what they want and cut costs.

Indeed.

By Evan Falchuk

As the physician work force continues to change, even leading healthcare states like Massachusetts are having serious problems having enough doctors.  According to a study by the Massachusetts Medical Society, seven of 18 specialties are in “critical” or severe shortages:

It is worrisome that two of the major areas of shortage are internal medicine and family medicine.  These doctors are the foundation of a well functioning healthcare system .  They are the doctors who should be able to understand the big picture of your health problem, and help guide you through the system.  Shortages in these areas mean those doctors who remain become more time-strapped, making it even harder to put together all of the fragmented information in each patient’s case.

Maybe innovations like accountable care organizations and investments in health care information technology will help, over time.  But for now, at a time when we need as many good doctors as we can find, reports like this are not good news.

In Australia last week, an eminent doctor showed me this quote about health care quality:

So I am called eccentric for saying in public: that hospitals, if they wish to be sure of improvement, (1) must find out what their results are, (2) must analyze their results, to find out their strong and weak points; (3) must compare their results with those of other hospitals and (4) must welcome publicity not only for their successes but for their errors.  Such opinions will not be eccentric a few years hence

It’s ironic that I’d first see this quote in Australia – since the quote belongs to Dr. Ernest Amory Codman, a doctor from my hometown of Boston.  It’s also sad, since Dr. Codman made this “eccentric” comment almost 100 years ago.  And while every other kind of business that wants to improve quality does what he says, for hospitals and doctors and policy-makers this kind of thinking is still kind of…edgy.

After a century, it’s time to start making this real in health care.

By Evan Falchuk

Watson, IBM’s powerful artificial intelligence system gained huge notoriety on Jeopardy! by defeating the show’s best-ever human player, is an important achievement.  It’s leading to the next question – what else can it do?  There’s a lot of talk that it could solve our healthcare quality problems.  Brandon Keim at WIRED magazine has written a very interesting piece on whether this is really something that is possible.

As a member of the Watson team put it:

A machine like that, with massively parallel processing, is like 500,000 of me sitting at Google and Pubmed, trying to find the right information.

It sounds good – but is a lack of knowledge really the problem in healthcare? Or is it a lack of time for doctors to build relationships with their patients?

Read the whole thing – it’s a provocative article.

By Evan Falchuk

Thanks to Casey Hobbs and Shayne Mason for a terrific interview broadcast today on Nurse Talk Radio.  We had a lively conversation about how to make sure you get the right diagnosis.

You can hear the entire show here – our conversation starts just before the 30 minute mark of their show.

By Evan Falchuk

Thanks to the American Benefits Council for the opportunity to present alongside Ray Goldberg of Marsh & McLennan Companies on the problem of misdiagnosis at the fall Policy Board of Directors meeting (I’m a member of the Advisory Council).  The American Benefits Council, under the leadership of their President Jim Klein, has cultivated great deal of respect in Washington, DC as a non-partisan, expert group on healthcare, employee benefits, and retirement security.  The quarterly meetings bring together 100 or more benefits leaders and experts from the nation’s leading companies for very candid discussions on how to attack the issues American businesses face.

Two important highlights to share.

Private Insurance Exchanges.  All of the political attention has been focused on what Democrats or Republicans might to with what so-called “Obamacare,” a centerpiece of which are state-run exchanges to create a competitive market for health insurance.  Meanwhile, parts of corporate America aren’t waiting for the government.  As you may have read in the papers, Sears, Darden Restaurants and some others have partnered with the benefits consulting company Aon Hewitt to create their own private health insurance exchange, and are enrolling employees.  Ken Sperling, the project’s lead at Aon Hewitt presented on what they had created.

What they’ve created is impressive.

They’ve partnered with insurers across the country to develop standardized plan options, and effective structures for employees to figure out which ones to buy.  While news reports describe the exchanges as meaning the employers are getting out of the health coverage business, that’s not exactly accurate.  Yes, financially, the employers are no longer taking direct health cost risk, they continue to run employer-sponsored and company-customized plans.  Still, the model is a radical departure from what most large employers do today, and is strikingly creative and innovative.  It won’t be for everyone (the initial indications are that about a quarter of employers would consider this model), but it shows how the creativity of American business leaders can solve seemingly impossible problems.

By the way, what this model highlights is how difficult it will be for state-run exchanges to have an impact on the large employer market.  If you have employees in, say, 25 states you would have to contract with state-run exchanges in 25 states.  And instead of dealing with benefits experts at Aon Hewitt, you will be negotiating with the state officials.  It’s another reason why sending employees to these exchanges may never be a practical alternative for large employers, even if it is for individuals or smaller businesses.  Aon’s experience with their exchange will be generating results so it’s something to watch very closely.

The Presidential Election.  As the ABC is very non-partisan, it hosted a debate between experts representing (but not surrogates for) the each of two presidential candidates.  Without delving into the details of the debate, I can tell you that each of these speakers gave far clearer descriptions of the differences between the candidates on economic and health care policy than I’ve ever heard the candidates do – and I’ve been paying attention.  It is very clear that the U.S. has more serious problems than most people think in terms of health care costs, the budget deficit, and the economy.  The clear impression I got from listening to these expert speakers is that the political parties are mainly focused on scoring political points on these issues, which was a stark contrast to the approach of the business leaders in the room.  I’d describe this as somehow being both dispiriting and hopeful…although maybe more dispiriting.

In all events, kudos to the Board and the staff of the ABC and the participants for a fascinating two days.