Sunday’s Milwaukee Journal Sentinel published an op-ed I wrote about how you can avoid misdiagnosis.

Published studies show that rates of misdiagnosis in America are a stunning 1 in 5.The good news is there are several steps you can take to protect yourself. They start with understanding why misdiagnosis happens, how you can work with your doctor to avoid it and, above all, playing an active role in your own health care.

Diagnostic errors happen much more often than most people realize. Even doctors are not immune. According to The New England Journal of Medicine, 35% of doctors have reported errors in their own care or that of a family member.

How can this be happening in a time of such great medical advances?

How indeed.  Go to the Journal Sentinel site and find out how you can protect yourself.

Bill Gates once said:

Success is a lousy teacher. It seduces smart people into thinking they can’t lose.

It’s clever, and it seems right.  Now there is science to prove it.

In a study published last week, scientists studied special imaging scans of doctors brains as they made simulated medical decisions.  Those doctors who paid attention to their mistakes made better decisions than those who were more interested in their successes:

“These findings underscore the dangers of disregarding past failures when making high-stakes decisions,” Montague said in a statement. “‘Success-chasing’ not only can lead doctors to make flawed decisions in diagnosing and treating patients, but it can also distort the thinking of other high-stakes decision-makers, such as military and political strategists, stock market investors and venture capitalists.”

This is just the latest proof of how important it is to interrupt your doctor’s decision-making process.  Leading researchers in the field of medical decision-making have emphasized how easy it is for “overconfidence” to get in the way.  Doctors are neither immune to disease nor the pitfalls of decision-making that plague the rest of us.

Guatemala is a developing country, with great natural beauty, hard-working people and many challenges.  Most Americans look at places like Guatemala and see only the challenges.  Some see opportunity.

I’ve just returned from Guatemala, where I met with our business partners, government officials, and others.   And I can tell you a universal truth.  People across the world want the best medical care they can get.  They aren’t looking for the latest technologies and drugs and treatments – or, rather, they aren’t looking only for those things.  No, what is most important to whoever I meet, no matter where they live, is that they are able to get the right diagnosis, and the right treatment.

It’s a harder thing to get in some places than in others.  Americans don’t realize that one of our great exports is our health care.  Not our system – but our know-how, education, medications, devices, techniques.  In many ways, health care promises to be the economic engine of 21st century America.  And getting access to it doesn’t necessarily mean getting on a plane and coming to the states.  At Best Doctors this is what we do – bring the expertise of the world’s leading doctors to where – and when – it’s needed.

After a speech I gave in Guatemala one of the audience members came to me and said she thought something I said was very important.  “Every person deserves the right diagnosis and treatment,” she said.  It’s a simple concept that is much harder to make reality.  But it should be the basis on which any health care program, health care provider – or health care system – must be built.

Atul Gawande says that we’re used to doctors working like “cowboys” – rugged individualists who are responsible for making sure your care gets done right.  We don’t need cowboys, he says.  We need “pit crews” – teams of doctors working together toward a common goal, with each playing their own role.

It’s an appealing idea.  Pit crew-like teams work, and work well, in trauma units across the country.

But there’s a problem: if you haven’t just been airlifted to a hospital after a horrible accident, you’re not going to be treated by a pit crew.  You’re going to be on your own, shuffled from one 15-minute specialist visit to the next, likely with no one person in charge of your care.

Dr. Gawande knows this, and he picks a heck of an example of the problem:

“But you can’t hold all the information in your head any longer, and you can’t master all the skills. No one person can work up a patient’s back pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the treatment of the unexpected cancer found growing in the spine. I don’t even know what it means to ‘protocol’ the MRI.”

Why is that such a good example?  Because it’s exactly what happened to my brother at one of the leading medical centers in the country.  He had a person directing the work up of his back pain and all the rest, including deciding on the right treatment for the “unexpected cancer found growing in his spine.”  It all worked well….except that he didn’t have cancer at all.  In fact, had he been treated for cancer, he might not be with us today.

The truth is when you get sick, there is no pit crew rushing out to help you make your way through the system.  There are overburdened, time-pressed doctors making decisions based on fragmented and often incomplete information.  Scientific studies showing diagnoses are inaccurate more than 20% of the time are a clear warning sign and a symptom of this public health crisis.

If you’re sick, you don’t have time for the system to change.  And so while we may not want our doctors to be cowboys, as a patient, you better learn how to be one.  Be self-reliant, demand answers, and, above all, know this:  the person with the greatest stake in getting your care right isn’t your doctor – it’s you.

Billionaire Teddy Forstmann has apparently been diagnosed with a serious form of brain cancer.  There’s a tragic twist to the story: according to Fox Business News, Forstmann believes that for more than a year, he had been misdiagnosed with meningitis.

ABC News wonders:

How could such a misfortune befall a billionaire —- a man able to afford the best doctors, best technology and the most sophisticated diagnostic tests?

They’re missing the point.  Misdiagnosis happens with shocking regularity – as much as 44% of the time, depending on the illness.

I’m sure that, as with most things, being a billionaire is better.  But as a neurosurgeon quoted by ABC News points out, even for a billionaire, getting the right care is “still a bit of a crap shoot.”

So how can you improve your odds?  Here are 5 tips that work.

1.  Know your family history – and remind your doctor of it. Don’t assume your doctor remembers that time you told him that two of your aunts died of breast cancer, or that your grandfather and father have a history of malformed blood vessels in their brains.  Research studies have shown that a family history may be a better predictor of disease than even genetic testing.  Find out about your family’s medical history, write it down (the Surgeon General has a good on-line tool to help you do this), and make sure your doctor knows about it – especially if you’re sick and they’re trying to decide what’s wrong.

2.  Ask questions.  The typical doctor sees as a many as 40 patients a day, spending 15 minutes or less with each one.  It’s all too easy to be referred to a specialist and start treatment without having all of your questions answered.  But asking questions won’t just make you feel more comfortable – it can disrupt your doctor’s thought process and make him think about your case in a way that may save your life.  Dr. Jerome Groopman, one of the world’s foremost researchers on how doctors think (he’s written the definitive book on it) agrees:

“Doctors desperately need patients and their families and friends to help them think. Without their help, physicians are denied key clues to what is really wrong. I learned this not as a doctor but when I was sick, when I was the patient.”

You can find some useful tips on how to do this at the U.S. government’s web site, called “Questions are the Answer.”

3.  Don’t Assume Technology Will Save You.  The best medical technology ever available is available today.  Still, studies show it is no more effective at getting the right diagnosis than a doctor piecing together your family history along with more traditional, low-tech tests.  If I had to pick between getting a high-tech test and a doctor who will spend an hour talking to me, thinking about my case and putting all of the pieces together, the research says I should pick the doctor.

4.  Don’t Always Trust the Tests. Some tests, like a review of pathology, can be wrong more than 40% of the time.  Why?  Because interpreting these tests is a matter of judgment, and experience.  As Dr. Lisa Sanders, who writes the New York Times’ Diagnosis column puts it:

“There are lots of diseases that can look like something else.  And that’s where clinical judgment and experience are essential.  Doctors see results as coming straight from God.  But just because a test gives you a yes or no answer doesn’t mean it’s right.”

5.  Get a Second Opinion.  But not just any kind of second opinion.  You need the doctor to look at your case from scratch – to hear you talk about your symptoms in your own words, and to think about your case without being influenced by the conclusions of your original doctor.  Don’t say “I was seen by Dr. X and he tells me I have meningitis and need treatment Y, what do you think?”  Instead, describe your symptoms, tell him about your family history, the tests you’ve had done, and help him come to his own conclusions about what’s wrong with you.  Of course, if you have Best Doctors, you can call us, since that’s what we do.  If you’re not satisfied with the answers, get another opinion – you only have one life, and maybe only one chance to get this right.

I’m in Israel, home to some of the most innovative care in the world.  Doctors here wanted to know if the high-tech tests that are an increasing part of their work help.  A couple of weeks ago, they published their results.

It turns out that in about 90% of cases, it didn’t matter.

A physical exam, the patient’s history, and the basic set of tests that doctors have done for decades was almost always all that was needed to get a diagnosis.  As one of the doctors in the study put it, “basic clinical skills remain a powerful tool, sufficient for achieving an accurate diagnosis in most cases.”

The conventional wisdom is that doctors – at least in the U.S. – order extra tests to protect themselves from getting sued.  But this study was done in Israel, where the problem of medical malpractice is nothing like it is in the U.S.  American-style defensive medicine can’t be the reason doctors in Israel use so many diagnostic tests.

Instead, the answer is revealed in a comment from a Canadian doctor who wasn’t involved in the study.  According to him, the use of high-tech studies has become so “routine” that doctors need to be reminded that they aren’t a replacement for actually diagnosing the patient.

There is something more fundamental happening – and it’s happening around the world.

To understand it, look to something that is happening in courtrooms across the U.S.  Some call it the “CSI Effect,” after the TV show, CSI.  In that show, a police team uses sophisticated technology to identify criminals with almost complete certainty.  Researchers have found that shows like CSI have changed jurors’ expectations of what kind of evidence the prosecution should be able to present.

Something like this is happening in medicine.

Patients show up with the expectation that the doctor will use sophisticated technology to get a quick diagnosis.  They’re often surprised to see how it really works.  Their doctor is rushed, uses paper files, and it can often take a long time before you get a clear diagnosis.  Doctors often order high-tech tests because patients expect it.

But doctors also do it because they are so pressed for time – because a test is a convenient short-cut that might reveal the answer without having to go through the trouble of asking questions, spending time with the patient, studying their medical history, and thinking about the meaning of more routine test results.

So are doctors lazy?  Do patients have overblown expectations of what doctors can really do?  Maybe.  But there is a more important truth which studies like this help reveal.

The most valuable piece of equipment your doctor has is his or her brain.  High-tech tests may give more information, but they are no replacement for your doctor’s training, judgment, and insight.

Sometimes you need a published study to tell you what should be obvious in the first place.

This time, researchers have discovered that:

When physicians have more personalized discussions with their patients and encourage them to take a more active role in their health, both doctor and patient have more confidence that they reached a correct diagnosis and a good strategy to improve the patient’s health.

Really?

But wait, there’s more.

The study also found that what they call “patient-centered care” (what other kind should there be?) saves money, too.  According to the study, the number of specialist referrals, diagnostic tests, hospitalizations, and total charges were reduced in the population of patients that got this kind of care.

This seems like the kind of thing we should be building our health care system around.  Unfortunately, the most important building block for patient centered care – the primary care doctor – is in short and dwindling supply.  Although 56% of patient visits in America are for primary care, only 36% of doctors practice primary care.  And among recent medical school graduates the numbers are even worse – only 8% plan to enter the field.

The health care reform law is set up to add fifteen thousand new primary care doctors by 2015 – and about 40 million newly insured people.  If these numbers are hit, the supply of doctors will barely keep up with even the existing demand.

What’s a patient to do?

Control the part of your care you can control.  Patients who are engaged, informed, active participants in their care do better than those who are not.  Your doctor may not have the time to practice “patient-centered” care, but it doesn’t mean you can’t be a patient-centered patient.  Ask questions, insist on answers, make sure your doctor spends the time with you that you need to be sure that the decisions you make are the right ones for you.  Use every resource available to you to make sure you get the right care.

It’s the kind of thing you don’t need a research study to tell you to do.

The New York Times says “In Medicine, New Isn’t Always Improved.”

Who can argue with this?

“In Dining, New Restaurants Aren’t Always Better.”

Yes, that’s true, too.  But does it mean anything?

The article is about a type of hip that is apparently going to be the focus of a lawsuit.  The story goes that a lot of people wanted the new hip when it came out, because it was thought to be better than the older ones.  Unfortunately, the hip seems to have hurt some people, some of whom may have been better off getting the older one in the first place.

A doctor quoted in the article suggests it’s part of a uniquely American tic.  We want all of the latest and greatest things for ourselves, it seems.  This story is supposed to be a cautionary tale of what can go wrong when we do.

On the other hand, the latest and greatest things don’t appear out of nowhere.  In America, when people demand something, there will be someone who supplies it.

It’s true.  Doctors, researchers, the government, and, yes, for-profit companies, create things.  They invent diagnostic tests and treatments for disease that never existed before.  One reason why the U.S. has a trillion-dollar health care economy is because there are so many people creating so many new things that people can sanely talk about curing – or at least managing – all disease.  This is a good thing.

But all these breakthroughs are a two-edged sword.

The ability to create increasingly precise treatments means it’s more important than ever to diagnose patients correctly.  Published studies show that misdiagnosis rates are as high as 44 percent.  These studies show these errors happen because doctors are pressed for time, seeing 30 or 40 patients a day.  But whatever the cause, twenty-five percent of patients can’t possibly benefit from the latest medical advances – because they just don’t have the disease for which they are being treated.

Today we have the most medical knowledge, technology and treatments than at any time in history, and yet it’s harder than ever to get people the right care.  Policy-makers must fix an overburdened health care system in serious need of repair.  Let’s get back to basics.  Let’s put a premium on doctors’ judgment, not on how many patients they can see in a day.

At the New York Times’ City Room Blog, Joel Cohen writes:

my wife and I are convinced that all medical students should have to pass Overbooking 101 before they can become doctors.Again and again, we arrive at a doctor’s aptly named waiting room on or before the scheduled time, only to learn that three or four others sitting there have been given the same appointment.

He says doctors need to understand the impact of this on their patients.  I agree, but not just because it’s annoying.

A typical doctor sees thirty patients a day.  Some see even more.

Reflect on that math.  If your doctor sees 30 patients a day, that’s 150 a week, 600 a month, maybe 7,000 a year.

It means that if it’s been even two months since you last saw your doctor, he has probably seen more than a thousand people since your last visit.  It’s why there’s often that moment of disconnect when you see your doctor.  You’re living every day with the fears and anxieties of your medical condition, but your doctor can’t quite place which one of the worried patients you are.  So you have to remind him why he ordered that extra test a few months ago, why you switched medications the last time you were there, how he already ruled out that possibility the last time he saw you.

We all work through these awkward moments- but they are a symptom of a more serious problem.

Doctors who are starved for time in a patient visit are also starved for time to think about their patients, reflect on what is wrong, and find good solutions.  It’s why studies show such alarming rates of incorrect diagnosis and treatment.

But what else can a doctor do?  There’s a room full of patients outside.  Just like there was yesterday, and just like there will be tomorrow.

Media reports on misdiagnosis continue to mount.

A recent study on patients with Alzheimer’s found that half had been misdiagnosed.  Half.

Another headline blared “4 out of 10 patients being misdiagnosed.”  The article encouraged patients to “see another doctor” if they are worried about their diagnosis.

You know what it makes me think about?

Starbucks.

Why?

Because the way Starbucks revolutionized coffee drinking shows a way forward for health care.

Starbucks realized that since our lives focus on two places – home and work – most of us don’t have a “third place” to go.  A place where we can be free of everyday distractions and take care of ourselves.  Starbucks set out to create that “third place,” by making its stores comfortable, inviting places.  It works.  “Third place” makes customers’ lives better – and Starbucks has almost 20,000 stores to prove it.

It’s time for a kind of “third place” in health care.

Health care focuses on two places, too: the doctor’s office and a hospital.  Both places are difficult for patients.  Patients complain of not getting enough time from their over-worked doctors, and studies of things that go wrong in hospitals are equally disturbing.

There really isn’t a “third place” to go to in health care.  Somewhere that you can step outside of the difficult process of being sick.  Somewhere you can get a quiet, clear perspective of what is going on.

Now, some people are lucky and can turn to relatives or friends who are doctors to provide some of that “third place” experience.  But most people cannot.  At Best Doctors, we’re creating the experience of a health care “third place.”  We do it by taking the time to review each case, have doctors think about what’s happening, consult with experts, and share advice.

In 2010, we found incorrect diagnoses in more than 20% of cases of the cases we reviewed.  We found incorrect treatment plans in more than half of cases.  These data match independent studies of misdiagnosis and faulty treatment.

Consider Rosa (not her real name), a 45-year old woman.  She had been having trouble with her thyroid, and after a biopsy came back “inconclusive,” she endured months of treatments that didn’t seem to help.  As part of her benefits package at work, she had Best Doctors and so she called.  She was worried, but mostly she was frustrated that she couldn’t get answers to what was happening to her.

We collected her records, reviewed them, and identified the important issues in her case.  We consulted with an expert in the thyroid problem the doctors thought she had.  He said the “inconclusive” finding on the biopsy and the lack of response to treatment were worrisome signs of cancer.  He recommended she have her thyroid removed.

Roslyn shared this information with her doctor.  The doctor agreed, and she had surgery to remove her thyroid.  It turned out that the thyroid was riddled with cancer.  It was a missed diagnosis that could have threatened her life.  Today, Roslyn is doing very well.

Stories like Roslyn’s are familiar to anyone who has faced illness, and is one of the ironies of modern health care.  We have the best trained most capable doctors in history, and yet it can be harder than ever to get the right care.  The increasing demand for what we do speaks to the need consumers feel to find health care’s “third place.”