Readers Write: Lessons From an Emergency Room Nightmare
About 16 percent of Americans don't have health insurance. For them, dealing with an illness often means either getting socked with a costly out-of-pocket appointment or simply going without care. That's a story the media tell us almost daily. What we don't often hear about is the quality of care for the 84 percent of Americans who do have health insurance. For them, seeing a doctor can be both a blessing and a gamble.
Doctors misdiagnose their patients up to 15 percent of the time, according to an article in the May issue of the American Journal of Medicine. And missed or wrong diagnoses account for a full 17 percent of "adverse events" in hospitals, a landmark Harvard study shows. Diagnostic errors can happen just as easily for benign conditions as for potentially fatal ones. Since every person's body is different, telltale symptoms can be present in one person and absent in another, or they could be ambiguous: Strep throat could masquerade as something else; so could cancer.
With Veronica Pollack, it was a heart attack. Or so the physician at her local hospital thought. Chest pains radiating down her arms and certain out-of-whack cardiac enzyme levels, consistent with heart attacks, masked the real culprit: a viral infection. Several mistakes led to a wrong diagnosis, and several more mistakes -- and flaws in the health care system -- kept physicians clinging unquestioningly to that diagnosis for nearly a month.
Her husband, Harold, recounted the ordeal in his recent article "Lessons from an Emergency Room Nightmare." The story left AlterNetters in a frenzy, with dozens of readers trying to figure out how the mistake happened (was it physician arrogance? lack of creativity? lack of time?) and how similar mistakes could be prevented (increased physician attentiveness? more knowledge on the part of patients?). In an effort to get at the truth, some readers shared their own health horror stories.
Here's a sampling of what they had to say:
"My experience has been that many health professionals have a very arrogant attitude, both about themselves and toward patients," writes pelican beak. ... "I'm talking about the type of arrogance that doesn't listen carefully to the patient, jumps to unwarranted conclusions, and then doesn't look back to ensure they're not mistaken."
"I agree with Pelican Beak about the arrogance of physicians (as a whole, with some wonderful exceptions)," writes SpiderWoman. "But there is another problem that is well-demonstrated in this article -- a lack of creative thinking."
The woman in this article had heart pain, so the ER doctors thought only one thing -- heart attack. It didn't matter that she'd had a viral infection or that she was an unlikely heart attack patient. Worse, though, is the fact that the doctors acted on their presumptions and proceeded with an invasive procedure -- one that was not needed, but placed her at risk.
This is much like my own experience, with the exception of an internist who was actually capable of real thinking and saw that this patient probably hadn't had a heart attack.
How did that internist figure it out? Not with tests or by reading the previous doctors' reports. Instead, he listened to the patient! That had not been done by any of the previous so-called specialists, who thereby missed the real issue, wasted time (days!) to get appropriate treatment to her and performed at least one dangerous and unneeded procedure.
This is a major issue in modern health care, and arrogance is a major reason for its existence and continuation.
TheLimit echoed SpiderWoman's sentiments, but with a caveat:
I think there's a strong sliding scale where arrogance is concerned. If you are clearly a well-employed, insured male, you are going to encounter much less arrogance than if you are a woman. If you are poor and uninsured, the arrogance will be in full force. If you are an elderly woman on a fixed income -- or a young single parent, you will generally see much more of it.
"Because I have bipolar disorder, my symptoms were completely ignored when I had reactions to medications -- I have had three requiring ER trips," writes DivaDeb. "One was to an anti-nausea drug that isn't used anymore (Compazine). I was told I was just 'keyed up.' I told them I know what manic feels like, and this is not it. They gave me a Benadryl and sent me home. I was a nutcase for over a day while that drug left my system -- I couldn't sit still, was twitching and was intensely afraid -- it made me temporarily semipsychotic."
Other readers, including some physicians themselves, questioned whether doctors have the adequate time needed to make an accurate diagnosis.
"Appointments to see a primary care doctor in the U.S. are typically 15 minutes in length, during which providers are usually asked to deal with at least three to five concurrent medical issues," writes mjabele. "This represents all the time given to: 1) listen to and interview the patient, 2) perform a directed physical exam, 3) review the patient's chart, 4) cogitate, 5) order necessary lab work, X-rays, and/or other tests/referrals, 6) write/renew prescriptions, and 7) explain the diagnostic/therapeutic plan to the patient, with sufficient time for questions if the patient should have any. ...
"I think it was William Osler who said, a century or more ago, that '80 percent of the patient's diagnosis comes from the medical history.' I daresay most modern physicians, despite fantastic advances in technology, would agree. But obtaining a good history takes time, and sufficient time seems to be the one thing our modern-day health care system wants to deny us. There's little point in asking questions, after all, if one doesn't really have time to listen to the answers.
"As for 'arrogance,' I wonder how much of what patients perceive is really a combination of the harriedness, anxiety, exhaustion and distraction so many providers feel as they navigate their impossibly packed schedules every day, essentially hoping to 'survive till closing time' without making any major mistakes along the way. I know I've felt that way much of the time; and though I've always done my best to listen, examine, empathize and advise as professionally as the Oath demands, I won't claim there might not have been days when my own patients might have perceived me as more distracted and less caring than I should have been."
"No one can keep up that pace without running on automatic," adds oregoncharles. "That can read as 'arrogance,' which is also fed by the patient's extreme dependence and the doctor's very real superiority in knowledge."
mam01 explains that, in Pollack's case, a wrong diagnosis was likely less about arrogance or time constraints and more about diagnostic methods:
When someone presents with worsening chest pain and elevated cardiac enzymes, a doctor has to make some pretty quick decisions, and it's not unusual to start from the worst-case scenario -- the heart attack -- and work backwards from that.
Given that a misdiagnosed heart attack has more dire consequences than a viral heart infection, and given that women tend to have more atypical presentations for a MI, I can understand why the diagnosis was made, and I don't believe it has anything to do with arrogance as some comments have suggested.
Why no one picked up on the error illustrates how we see what we want to see and disregard those facts that don't quite fit. This is even more so when the diagnosis continues to be confirmed by other specialists. That's why it takes someone with fresh eyes and the time to study the chart to see the error.
And it's why the practice of medicine is both an art and a science.
While most commenters placed the onus of getting a correct diagnosis on physicians, others said patients, too, should play an important role in preventing medical errors.
"if you have any health issues, it is up to you to gather as much info on them yourself, including medical journals, other relevant articles and a cram course in basic anatomy of your offending body part," writes ellie. "know what the protocol is for all treatment of such offending body part and become a member of your own medical team...
"let the 'professionals' understand that it is your body and you have last word on treatment and options... if they balk, keep on dr. shopping till you assemble a team you can work with and listen to you..."
ladyoracle stresses that second opinions can be critical:
"I was almost released from an ER when I came in at age 28 after coughing up blood after a workout. It turned out that I had pulmonary embolisms, but they only did an X-ray the first time and checked my vitals, and I guess blood, and they couldn't figure out any reason to keep me. so they were going to give me an antibiotic and send me home when I was in pain with every breath. I heard the doctor tell that to my nurse standing a few feet from my room, so I coughed more blood into a Kleenex, but instead of throwing it away like they were telling me, I brought it out there to show it to them. A pulmonary specialist who was there to review a different case overhead me and suggested a CT scan, which then showed the clots. They let me walk to get the CT scan, and then after that I got an IV in the stomach and total bed rest for 48 hours. So, they avoided the mistake that would've probably cost me my life, but they didn't take my blood for the hematologist until hours later, and then more the next day, after I'd already been on blood thinner. My blood showed no abnormalities at that time, but clearly something was amiss, which is another comment for another day. The point is that what saved me is a second opinion."
beachcomberT says that diagnostic mistakes "in a health system driven more by cost factors than what's best for the patient" should not come as a surprise: "Insurance companies are doing all they can to steer people away from costly tests and emergency-room visits, preferring they go to cheaper urgent-care stations. Besides publicizing mortality stats of hospitals, let's have some mortality stats on health insurance companies. It's relatively easy to find out which ones are making the most money; virtually impossible to find out which ones are doing a good job at saving lives."
A for-profit system can also work against patients by causing them to delay or avoid care for fear of outrageous costs. That can be true for uninsured and insured patients alike. Pollack, the author of the article being discussed, admitted money was in the back of his mind when he and his wife were trying to decide if she really needed medical attention or not. "We were ... swayed by the expected hassle and expense of an ER visit," he writes. "We envisioned paying a large bill to be prescribed some Tums. Last year, Veronica went out-of-network for urgent care. That cost $700."
AlterNet reader driftwolf, who has lived in several countries, writes that "one thing stands out about this article: the overwhelming worry about cost. About going bankrupt just because someone in your family is sick, even if you have health insurance, just because they might not cover it or you're going (a term I've not heard before) 'out of network.'
"That, to me, is just wrong. Completely, utterly, irreparably wrong. It's sick. It's disgusting. It does not belong in a society that prides itself on being 'better' than everywhere else.
"For me, it's another good reason to stay away from the U.S. and keep to countries that understand and act upon the ideal that the health of its citizens really is the most important 'national security' issue you can have."
As health care continues to become a larger and larger part of our national dialogue, AlterNet will keep you up to speed on the conversation. So check back often, and keep those comments rolling.
Some other great health care stories you might have missed this year: Cancer at 23: How Health Insurance Failed Me by Carey Purcell, Criminal Health Care: My Experience in Insurance Company Hell by Eric Stoner, and Want to Save Some Lives? Here is a Simple Formula for Identifying Strokes by AlterNet's Don Hazen.