[Reblog] Beware your doctor’s knee-jerk reflex: 3 questions to ask
From the 3 September 2014 post at KevinMD.com
In summary
1. Always ask “why?” This seems obvious, but even in this modern era, many patients take it as an article of faith that a doctor’s recommendation is thoughtful and well informed. It may well be; but on any given occasion, it could also be a knee-jerk — born of prevailing tendencies, distractions, and want of time. The question “why” is easily addressed by those who have already thought it over; and is a necessary reality check for those of us who have not.
2. Always ask “what else?” In the case of the fluoroquinolone syndrome, it’s bad enough when a fluoroquinolone was a genuinely thoughtful, warranted choice. It’s downright tragic when a much-less-potentially-toxic, narrow spectrum antibiotic would have served at least as well. “What else?” is a reminder that there is generally more than one way to test or treat, and the one we want is the BEST of them: most likely to help, least likely to hurt. It prods our providers to do the extra work of getting us there when we remind them we want to know the options, and comparison shop them.
3. Always ask “then what?” This would certainly defend against a screening colonoscopy in an 85 year old with congestive heart failure. If I have this test, then what? The answer would have to be: We can find potential cancer early, and fix it now so it doesn’t cause you trouble in ten years. That would invite all concerned to revisit the relevance of that “help” ten years in the future of someone exceedingly unlikely to live that long.
Related articles
[Press release] Care of patients prior to making a diagnosis rarely assessed by quality measures
Care of patients prior to making a diagnosis rarely assessed by quality measures
From the 3 February 2015 press release
An examination of process measures endorsed by the National Quality Forum finds that these measures focus predominantly on management of patients with established diagnoses, and that quality measures for patient presenting symptoms often do not reflect the most common reasons patients seek care, according to a study in the February 3 issue of JAMA.
Health care reform efforts, such as accountable care organizations, focus on improving value partly through controlling use of services, including diagnostic tests. Publicly reported quality measures that evaluate care provided prior to arriving at a diagnosis could prevent financial incentives from producing harm. The National Quality Forum (NQF) currently serves as the consensus-based quality-measure-endorsement entity called for in the Affordable Care Act. Endorsed measures are often adopted by the Centers for Medicare & Medicaid Services in payment and public reporting programs, according to background information in the article.
Hemal K. Kanzaria, M.D., M.S.H.P.M., of the University of California, Los Angeles, and colleagues examined NQF-endorsed process measures that evaluate the prediagnostic (prior to making a diagnosis) care of patients presenting with signs or symptoms. There were 372 process quality measures listed on the NQF website as of June 4, 2014; from these, 385 codings were determined, by categorizing the process quality measures by a system developed by the Institute of Medicine. Approximately two-thirds (n = 267) targeted disease management and 12 percent (n = 46) targeted evaluation/diagnosis. The remaining were evenly distributed among prevention, screening, and follow-up.
Of 313 measures pertaining to evaluation/diagnosis or management, 211 (67 percent) began with an established diagnosis, whereas 14 (4.5 percent) started with a sign/symptom. The sign/symptom-based measures focused on geriatric care (e.g., memory loss, falls, urine leakage) or emergency department care (e.g., chest pain). In contrast, many common reasons for which patients seek care, including fever, cough, headache, shortness of breath, earache, rash, and throat symptoms, were not reflected by the quality measures. The performance of a lab test or medical imaging study was the action required by 59 of 313 (19 percent) endorsed quality measures; many others required actions related to medication prescribing.
[News item’ The patient from the future, here today
Two thoughts on disparities highlighted in the article
What about folks who do not have the background and access to resources to self diagnose? In all countries, “developed” (as USA, most of Europe) and “developing” (asmuch of Africa, parts of Asia…)
Is it ethical for some health information to be physician/research access only?
From the 5 March 2014 UT-San Diego article
By 1997, those irregular heartbeats became common, leading to “hundreds and hundreds” of serious episodes, capable of causing death. She eventually received an ICD, an implanted cardioverter-defibrillator, which would shock her heart back into the proper rhythm.
Goodsell began studying her condition, drawing back on her own education. While she has no medical degree, Goodsell had been a pre-med student at UC San Diego, where she met Charles, who was studying chemistry. She dropped out after falling in love with nature during a trip to Peru.
Looking for that unifying theory, Goodsell delved into genomics, searching for mutations that could encompass her symptoms. She found it with a gene called LMNA, that codes for making proteins called lamins that stabilize cells. Defects in these proteins can cause a form of Charcot-Marie-Tooth disease, damaging nerves in the extremities and causing muscle wasting, including in the hands.
Symptom after symptom checked with the mutation. But to be sure, she needed a genetic test, and her Mayo doctors resisted.
…
Taking the research into self-therapy, Goodsell researched risk factors associated with the disease, examining what goes on at a molecular level. She changed her diet: Out went sugars, out went gluten and any food with additives. And out went a beloved snack.
“I used to eat bowls of jalapeño peppers. I discontinued.”
But she added certain fats she had previously avoided, such as omega-3 fatty acids and nuts, which are rich in fats.
“Cell membranes are fat, and we need fat — good fat,” she said. “I was advised to start eating fat.”
Goodsell said her symptoms improved. Control over her hands improved enough to allow her to eat with chopsticks and to resume kitesurfing.
Goodsell’s doctor wrote up her case history, listing her as co-author “because he said I had done the lion’s share of the work.” The study is to be presented at an upcoming meeting of the Heart Rhythm Society.
Related articles
Epatients: The hackers of the healthcare world [O’Reilly Radar]
- Are you an ePatient? (enbloommedia.com)
- The Rise of the e-Patient: Slideshow (ScienceRoll)“It’s always good to see the trends about the growing number and importance of e-patients. Lee Rainie, director of the Pew Internet Project, presented this wonderful overview of the Project’s health findings at Providence St. Joseph Medical Center in Burbank, CA, on January 12.”
- Why patients are turning less to media and friends for health information (jflahiff.wordpress.com)
- Can differential diagnosis be crowdsourced to Facebook Friends?(medgadget)
- ePatient Connections: A Patient Checks In. (sixuntilme.com)
- From E-patient Hackers to Health Games on Mobiles (scienceroll.com)
- The end of social – O’Reilly Radar (queuniversidade2.wordpress.com)
- Meet e-patient Dave – a voice of patient engagement (and related resources) (jflahiff.wordpress.com)
- 2020 Vision: The ePatient Evolution Over the Next 10 Years (prweb.com)
- ePatients Come Together to Brainstorm and Share (brassandivory.org)
- 6 P’s Of Social Health (socialmediaclub.org)
- The Rise of the ePatient – presentation by Pew Internet Project (casesblog.blogspot.com)
Meet e-patient Dave – a voice of patient engagement (and related resources)
[Journal Article] Search engines cannot diagnose through symptom searching – only 14% accuracy
Ever enter your symptoms into a search engine (as Google) to find what was the cause? And bring the results to your health care provider? Believe that search engines can correctly diagnose your symptoms?
A medical researcher not only was thinking along these lines. He also set up a system to see if search engines could diagnose symptoms accurately.
The results were published in a scientific paper.**
Here are some remarks from medical librarians at their discussion group.
- They don’t address the problem with these search engines of bias: Google,
Bing, track what you’ve searched on, they aren’t ‘anonymous’ engines, thus
biasing the results. A different computer, with different previous user
will give different results with these search engines. Flawed article,
in my opinion. Too bad, it is interesting.
- This article is very interesting. While it is about validating the instrument for analyzing the webpages, they found that only 14% of the website gave a correct diagnosis. Seventy percent came up with the diagnosis as part of a differential. It sort of scares me that many medical students and other healthcare students might use search engines to find differentials. One implication is that patients who bring in webpages may actually hold the appropriate differential in their internet printout. Physicians might consider that information. The article is NOT an open access journal. The abstract does not discuss the findings of accuracy since they were testing the scoring system.
My thoughts? Familydoctor.org (American Academy of Family Physicians) has great advice
Our symptom checker flowcharts allow you to easily track your symptoms and come to a possible diagnosis.
Remember, be sure to consult with you doctor if you feel you have a serious medical problem.
As a medical librarian, we counsel people to use any information they find as a resource when consulting with their health care provider. Information on the internet may be outdated, flawed, and sometimes even wrong.
Also, the health care providers views you as a whole person, not just a narrow set of symptoms. They use not only your symptoms, but other factors as health history, current and past treatments, and environmental factors to work toward a treatment plan.
Related Resources
Online symptom checkers (Standford Health System)
** Abstract from PubMed.
Full text of article not available online for free.
Might be available for free or low cost at a local public, medical, or academic libary.
Call ahead and ask for a reference librarian.
Many medical and academic libraries offer some help to the public.
Int J Med Inform. 2014 Feb;83(2):131-9. doi: 10.1016/j.ijmedinf.2013.11.002. Epub 2013 Nov 19.
The accuracy of Internet search engines to predict diagnoses from symptoms can be assessed with a validated scoring system.
- Rutgers Robert Wood Johnson Medical School and Rutgers Robert Wood Johnson Family Medicine Residency at CentraState, United States. Electronic address: bshenker@centrastate.com.
The High Cost of Not Listening to Patients.
This article reminds me of my days as a medical librarian.
If I did not carefully listen to a patron (customer) or ask the right questions, I gave the person the wrong information!
Minutes spent in listening and asking focused questions often saved an hour (or more!) of fruitless searching.
So, when I talk with a health care practitioner, I am mindful to give as much relevant information as possible to so the proper diagnosis and treatment can be given!
It is also necessary that we all do whatever we can so that health care practitioners are given the time they need to listen to patients.
Ultimately this will result in lower health care costs overall.
From the 18 January 2013 post at The Health Care Blog
Before we can understand the high cost of not listening, we need to examine in detail the diagnostic process. I am limiting my discussion to patients with chronic or recurring symptoms lasting several months. I am not discussing acute illnesses. They fall into completely different category.
At the front line of medical care, at the first contact between a patient and a doctor, the patient describes physical symptom. Whatever the real underlying cause, a physical symptom is the required ticket to see a physician. The physician, on first contact, has no idea what the underlying nature of the patient’s chronic complaint really is. At the risk of oversimplifying, there are five broad categories of the causes for complaints.
These are:
1. There is a definable medical disease in one or more organs.
2. There is no definable medical disease but the patient is in contact with an unknown toxic substance causing the symptom (inhaled, ingested, or from skin contact).
3. The patient is in a stressful or toxic relationship at home or work producing physical symptoms or even a definable medical disease. (“What the mind cannot process is relegated to the body.” Dr. William Mundy, psychiatrist, personal communication. )
4. The patient or a companion is inflicting harm. Here, there are several categories:…
…
5. There is no definable medical disease but the patient has assumed a chronic illness role in life with multiple symptoms (i.e. hypochondriasis).
Psychosomatic Illness
6. There is a sixth category; patients with psychosomatic disorders. Time and space does not permit a full discussion of this important and very common set of disorders. I suspect they represent more than fifty percent of patients seeking primary medical care. The book“The Divided Mind” explains and defines these disorders and the successful treatment applied to thousands of patients at NYU by Dr. Sorno and his colleagues. At present the medical profession denies the existence of this category. The epidemic emergence of pain clinics comes from lack of knowledge about psychosomatic disorders and their proper treatment.
Of course, the patient can have any of these, and also be suffering from a definable medical disease.
But my experience in primary care over the past 55 years — combined with studies in the medical literature —suggest that between 30 and 40 percent of first contact primary care visits are stress related or are psychological in nature (#3 and #6 in above list).
It should be obvious that the only way to sort out these causes of symptoms requires very careful listening to the narrative of the patient’s life. Some of these causes can be determined only by listening…..
More information does not equal better care
Chalmette, LA, December 16, 2005 – A patient describes his symptoms with a nurse at the Primary Care Clinic in St. Bernard Parish. The facility located in a triple-wide office trailer offers free medical care to area residents, staffed by personnel from the U.S. Public Health Agency and FEMA Disaster Medical Assistance Team (DMAT). Robert Kaufmann/FEMA
A wise, sobering post on the limits of medical/health related information.
Technology is increasingly used to collect and store personal health and medical data. While the amount of personal stored data is rising, this does not necessarily translate into better care. For example, the information stored in electronic medical records is only as good as the data entered. Medical devices (as imaging and gene testing instruments) generate data that may or may not be useful depending on why they were ordered and how they results are interpreted.
The use of the data is also troublesome. As this post states, medical test results are often misused by the diagnostics industry in over testing. This leads to unneeded treatments which divert money and resources. Health care providers, especially those in primary care have less time to listen to and counsel patients.
The money spent on unnecessary treatments is a burden not only on individuals, but also health care facilities and government agencies. Health care facilities become caught in a spiral of justifying diagnostic equipment through marketing and at some point they will find it nearly impossible to recoup their investments. Medicare and Medicaid funds are not used wisely to diagnose and treat, resulting in ever more increased costs to the system.
As this post points out, health care providers would be wise to take a deep look at their role and be realistic about their expectations.
The same can be said about those who consult with health care providers.
From the 1 November 2012 article at KevinMD.com
I have found that this concept is hard for non-healthcare people to really grasp – that a less aggressive testing approach knowingly misses disease, but makes no difference in the overall prospects of the patient. It is crucial that the U.S. culture fights the prevailing scare tactics of the diagnostics industry, or we’ll never lower the rate of over testing. Any administrative tricks to lower testing rates will be subverted by both physicians and patients who assume more tests equal better care unless the underlying culture and conventional beliefs are changed.
The change required is deeper than administrative rules. It has to come from a more humble attitude on the part of doctors, patients, employers, and insurers that just because a patient could be labeled as having a disease, there is nothing to be gained by doing anything about it. More information does not equal better care.
Our American culture proclaims, “Just Do It.” To reclaim resources from the healthcare industry and return them to the general economy, we must proclaim, “Don’t just do something for the sake of doing something, stand there.”
Related Resources
- US Agency for Healthcare Research and Quality (AHRQ)- Consumers and Patients
- Evaluating Health Information (Health Resources for All Edited by Janice Flahiff)
Related articles
- Why Health Care is a Civil Right (jflahiff.wordpress.com)
- Misinformation in electronic medical records has consequences (kevinmd.com)
- Shared Decision Making Leads To A Better Patient Experience And Higher Levels Of Patient Satisfaction (introcomm)
- Supplies and Devices Are Biggest Cause of Hospital Cost Increase(jflahiff.wordpress.com)
- 9-part series on over-diagnosis (HealthNewsReview.org)
9-part series on over-diagnosis (short reads from a health care journalist)
Over-diagnosis happens when people are diagnosed with diseases or conditions that won’t actually harm them.
From the 3 October 2012 blog article by Gary Schwitzer at HealthNewsReview.org
Ray Moynihan, a terrific health care journalist who is now pursuing his PhD on overdiagnosis and working as a Senior Research Fellow at Bond University in Australia, kicks off the first of a nine-part series, “Over-diagnosis Epidemic” on TheConversation.edu.au website.
The first part is an introduction, “Preventing over-diagnosis: how to stop harming the healthy.”
“To put it simply, over-diagnosis happens when people are diagnosed with diseases or conditions that won’t actually harm them. It happens because some screening programs can detect “cancers” that will never kill, because sophisticated diagnostic technologies pick up “abnormalities” that will remain benign, and because we are routinely widening the definitions of disease to include people with milder symptoms, and those at very low risk.”
Other colleagues author the subsequent parts in the series:
Part two: Over-diagnosis and breast cancer screening: a case study
“…But what we found was that the greatest relative reduction in breast cancer mortality (44%) occurred in the youngest age group. These women (aged 40 to 49 years) are not invited for screening. In contrast, women aged 60 to 69 years, who areinvited to screen, had the smallest relative reduction in mortality (19%).
Given that three times as many women aged 60 to 69 (about 60%) participated in Breastscreen (compared to 20% of women aged 40 to 49 years), our finding is not consistent with screening having a major impact on the reduction in breast cancer mortality since 1991.”…
Part three: The perils of pre-diseases: forgetfulness, mild cognitive impairment and pre-dementia
“…Most studies show that only one in ten cases of mild cognitive impairment progress to dementia each year, and many improve. One study that followed outcomes for ten years concluded – “The majority of subjects with MCI do not progress to dementia at the long term.”…
Part four: How genetic testing is swelling the ranks of the ‘worried well’
“..A major concern with such tests is that they’re the beginning of a path toward over-diagnosis, where the potential to develop a disease or being at risk for the disease is strong enough to constitute a label of sickness.
Over-diagnosing includes, but is not limited to, widening disease definitions, early detections of abnormalities that may or may not cause symptoms or death and the use of increasingly sensitive technologies that detect “abnormalities,” the causes and consequences of which are unknown at this time…”
Part five: PSA screening and prostate cancer over-diagnosis
Part six: Over-diagnosis: the view from inside primary care
“..The most common reason general practitioners are sued is because of missed diagnoses. Missed diagnoses also invoke a strong sense of professional failure. So how can general practitioners manage in this sea of uncertainty?
One way is to perform more tests. This is also popular with patients, who perceive that tests ensure nothing serious is missed. What is not well understood by patients (and sometimes also by clinicians) is the potential harm from testing.
The most obvious harm is the cost and resources required; we would quickly overwhelm the health system if we performed an MRI on every patient with back pain. A strong system of primary care results in a health-care system that’s both more efficient and less costly because primary-care physicians are skilled at filtering those with severe disease needing further tests, from those with self-limiting illnesses…
…
The greatest harm from the increased use of testing, however, is not costs, resources or false positives. Rather, it’s the problem of over-diagnosis.
Clinicians and patients both believe that finding a disease earlier in its process means it will be more successfully treated. But there’s increasing evidence that finding disease early or at a milder stage has paradoxical harmful effects, even reducing survival and quality of life.
Wider availability of more sophisticated tests results in “incidentalomas”, incidental findings that would not have otherwise been diagnosed. The detection of thyroid cancers, for instance, has more than doubled in the past 30 years. But most of these diagnoses are incidental findings from imaging…”
Part seven: Moving the diagnostic goalposts: medicalising ADHD
Part eight: The ethics of over-diagnosis: risk and responsibility in medicine
Part nine: Ending over-diagnosis: how to help without harming
Related articles
- #Preventing #over-diagnosis #good #healthy (leggotunglei808.wordpress.com)
- What good is a diagnosis? (wisecounsel.wordpress.com)
- Biopsies may misdiagnose eosinophilic esophagitis (yvonnebergeron.wordpress.com)
Doctors Overlook Chemical Illnesses, Study Finds
While I know folks who are prone to conditions triggered by chemical intolerances….am blessed that environmental chemicals don’t seem to affect me for whatever reason..
Am posting this especially for folks with chronic conditions of any kind. Please ask your health care provider if screening, testing,prevention of, and treating for chemical intolerances is right for you.
From the 10 July 2012 article at Science News Daily
Chemical intolerance contributes to the illnesses of 1 in 5 patients but the condition seldom figures in their diagnosis, according to clinical research directed by a UT Medicine San Antonio physician.
Clinical tools are available to identify chemical intolerance but health care practitioners may not be using them, lead author David Katerndahl, M.D., M.A., said. The study is in the July 9 issue of Annals of Family Medicine.UT Medicine is the clinical practice of the School of Medicine at The University of Texas Health Science Center San Antonio.
Avoidance of triggers
The study’s authors said physicians need to know how chemical intolerance affects certain people and understand that conventional therapies can be ineffective. Some patients would improve by avoiding certain chemicals, foods and even medical prescriptions, the authors said.
Patients with chemical intolerance go to the doctor more than others, are prone to having multi-system symptoms and are more apt to have to quit their job due to physical impairment, the authors said….
…Chemically intolerant individuals often have symptoms that affect multiple organ systems simultaneously, especially the nervous system. Symptoms commonly include fatigue, changes in mood, difficulty thinking and digestive problems.
Related articles
Related Stories
Self-Affirmation May Break Down Resistance to Medical Screening
From the 21 December 2011 News article
People resist medical screening, or don’t call back for the results, because they don’t want to know they’re sick or at risk for a disease. But many illnesses, such as HIV/AIDS and cancer, have a far a better prognosis if they’re caught early. How can health care providers break down that resistance?
Have people think about what they value most, finds a new study by University of Florida psychologists Jennifer L. Howell and James A. Shepperd. “If you can get people to refocus their attention from a threat to their overall sense of wellbeing, they are less likely to avoid threatening information,” says Howell. Do that, and people are more likely to face a medical screening even if it means undertaking onerous treatment and even if the disease is uncontrollable. The findings will appear in Psychological Science, a journal published by the Association for Psychological Science.
The researchers undertook three studies, each with about 100 students of both sexes. In all three studies, they asked the participants to think of a trait they valued; they chose traits such as honesty, compassion, and friendliness. Participants then wrote either about how they demonstrated the trait (expressing self-affirmation) or a friend (not affirming themselves) demonstrated the trait….
Related articles
- Self-affirmation may break down resistance to medical screening (medicalxpress.com)
- Self-affirmation may break down resistance to medical screening (eurekalert.org)
- When Are You Too Old For Routine Screening Tests? (aarp.org)
- Breast cancer screening saves lives – but it causes harm, too (telegraph.co.uk)
- African American Communities Face Aids Crisis (socyberty.com)
- Symptom-Based Screening May Improve Detection Of HIV In High-Risk Men (medicalnewstoday.com)
Most patients don’t need extra tests for diagnosis
A technician performs an electrocardiogram on a patient in the hallway of the emergency room at a hospital in Houston, Texas, July 27, 2009.
Credit: Reuters/Jessica Rinaldi
(Reuters Health) – Examining patients and taking a medical history are more useful to hospital doctors in diagnosing patients than high-tech scans, suggests a new study from Israel.
Doctors said that when tests such as CT scans and ultrasounds were given to patients right after they showed up at the ER, the imaging only helped in making a diagnosis in about one in three cases…..
Related articles
- Doctors Screen for Cervical Cancer Too Often (nlm.nih.gov)
- Why is it so difficult for doctors to stay on time? (kevinmd.com)
- iPads used for diagnosis and treatment in Texas hospital (tuaw.com)
- The value of time in medicine (medrants.com)
About
This blog presents a sampling of health and medical news and resources for all. Selected articles and resources will hopefully be of general interest but will also encourage further reading through posted references and other links. Currently I am focusing on public health, basic and applied research and very broadly on disease and healthy lifestyle topics.
Several times a month I will post items on international and global health issues. My Peace Corps Liberia experience (1980-81) has formed me as a global citizen in many ways and has challenged me to think of health and other topics in a more holistic manner.
Do you have an informational question in the health/medical area?
Email me at jmflahiff@yahoo.com
I will reply within 48 hours.
This blog is a companion site to my Health and Medical News and Resources Web site with…
- Great places to start (locating health information)
- Links to help from others (as health care providers and support groups)
- Interactive tools (as health calculators and apps)
- Select related news sites and blogs
My professional work experience and education includes over 15 years experience as a medical librarian and a Master’s in Library Science. In my most recent position I enjoyed contributing to our library’s blog, performing in depth literature searches, and collaborating with faculty, staff, students, and the general public.
While I will never be be able to keep up with the universe of current health/medical news, I subscribe to the following to glean entries for this blog.
- Science Daily – Your source for the latest research news
- MedlinePlus email updates from the US National Institutes of Health
- Partners in Information Access for the Public Health Workforce – a collaboration of U.S. government agencies, public health organizations and health sciences libraries
- US Agency for Healthcare Research and Quality (AHRQ) news now with updates on the agency’s efforts to “improve the quality, safety, efficiency, and effectiveness of health care for all Americans”
- Research Buzz, “news about search engines, digital archives, online museums, databases, and other Internet information collections since 1998”
- Scout Report, a “weekly publication offering a selection of new and newly discovered Internet resources of interest to researchers and educators”
- KevinMD.com -“Social Media’s leading physician voice”
- EurekAlert-Medicine and Health
Health and Medical News and Resources 