It’s tempting to begin this health tip with “Here’s the news from Lake Wobegone…” You’ll soon discover why as I tell you about two recent articles of note. Also, I’d be most interested in your interpretation from a health care consumer’s point of view.
The first article, published this week in JAMA Internal Medicine, reported the findings of an online volunteer group of 118 general internists who had agreed to participate in a unique study that tested both their diagnostic expertise and their self-confidence in that expertise. First, though, you need to know that physicians are regularly checked with test patients throughout their careers, usually as a prerequisite for recertification in their specialty. These tests can be quite complex, the physician starting out by reading the fictional patient’s history, physical findings, lab tests, and x rays. The doc may even be shown photographs of his or her “patient.” Then, using the old-fashioned multiple-choice format (but online), the physician chooses appropriate steps to manage this medical challenge, which will end either well or badly for the make-believe patient.
Until now, though, no one has examined the degree of self-confidence among physicians as they go through this diagnostic testing.
As a patient, ideally what you want is a doc who’s a good diagnostician, who listens to you, orders appropriate tests, and is reasonably confident in what she’s doing. But equally important, you want someone who, when confronted with a more complex diagnostic dilemma, is willing to say “Hmmm…I’m not sure” and order the additional tests required to reach a diagnosis and/or seek help from other sources, like a textbook, the internet, or another physician, either a colleague or by referring you to a specialist.
If that’s your kind of doctor, the article’s results are not good news.
Researchers presented physicians with four imaginary patients, two with easy diagnoses and two with quite difficult ones. Here’s a bullet-point list of results:
- The doctors’ ability to diagnose the easy cases correctly was just 55%. This means, of course, that 45% of the physicians missed one or both of the easy diagnoses.
- Physicians attempting the difficult cases fared very poorly, with only 5% diagnosing the challenging cases correctly.
- But the really bad news was the degree of personal self-confidence these physicians had in their diagnostic prowess–their reluctance to say, “I’m not sure. I need you to have more tests. I think you need to see a specialist.” In fact, and this is decidedly creepy, they were almost as confident misdiagnosing the difficult cases as they were misdiagnosing the easy ones.
There were all sorts of explanations for why this disquieting “wrong diagnosis made with confidence and reluctance to seek additional information” occurred. I’m sure everything has been suggested, ranging from attitudes learned in medical training or being overworked with too many patients to an ego-led belief in their own personal “brilliance.”
Doctors are docked financially for getting diagnostic help
To me the most disturbing possibility for this situation is a consequence of physicians being financially penalized by insurance companies for ordering “too many tests” or making “too many specialist referrals.” How many doctors have to force themselves into an artificial comfort zone, convincing themselves they’re satisfied with decisions that are clearly beyond the information they have available or clearly beyond their level of expertise?
As a quick example, if an insurance company penalizes a doctor for ordering too many MRIs, he’ll cut down on ordering them, to the delighted approval of the insurance company. After a year, if nothing goes wrong, he’s probably grown over-confident in his “I can make a diagnosis without an MRI” position. But when someone from the sheriff’s office delivers his missed-diagnosis malpractice suit, during the subsequent trial his excuse “but the insurance company told me to cut down on MRIs…” will get him exactly nowhere.
On that cheery note, here’s the second piece of bad news this week, very much related to the first.
The obscenely profitable UnitedHealthcare recently announced it was cutting thousands of physicians from its networks. Physicians in 11 states who were participating in one of United’s programs called Medicare Advantage received—literally–an unmarked plain envelope (many of the notifications were inadvertently tossed out as junk mail) informing them they were no longer “in network.” This meant that tens of thousands of patients had to scramble care elsewhere, records had to be transferred, and prescriptions required rewriting by doctors who didn’t even know these patients. I’m sure many of you have been through this.
The main criterion for a physician being dropped from a network is always (always always) a financial one. The physician or her group is red-flagged by the insurance company as an “over-utilizer.” This means too many diagnostic tests, too many referrals to specialists.
In other words, just when we learn that in order for physicians to be more effective they need to be willing to order more tests and refer patients to colleagues or specialists, BANG! They’re offed by the Godzillas of the health care system. It’s already started with UnitedHealthcare, and the other giants are watching the mounting legal battles (restraining orders have been filed by medical groups against United), but believe me, this is the future.
And that’s the news from Lake Wobegone. What do you think? Your comments are invited.
Be well,
David Edelberg, MD
PS: I was mightily pleased to learn that one of the solutions suggested to enhance physicians’ diagnostic expertise was something I’ve been doing for years (you who are my patients can affirm this). It’s called Point of Care Learning and what it translates to is having immediate help from both colleagues and the internet. I probably say to my patients “Give me a second while I look this up…” at least a dozen times daily.
As a quick and personal example, although I wasn’t part of the survey, I did tackle the cases that were presented to the doctors in the article. I correctly diagnosed the two easy cases, but admittedly joined the 95% who were stymied by the two difficult ones. However–and to me this is a big however–with the help of good old Google in about two minutes I got enough information to make (with pretty good confidence) the likely correct diagnosis of both.
And this is why the US ranks so low globally in so many metrics of health care effectiveness. For a nation with so much wealth, our health care is in the hands of insurance companies, not that of the physician. Deplorable.
Walt Polsky
I am terrified and infuriated that I am expected to trust my healthcare decisions to an insurance company.
I once had a primary care physician (assigned by an HMO), hold up his hand to stop me when I started to ask him about a health concern other than what I had made the appointment for. “Only one problem per visit.” he said.
For many years my healthcare has been managed by an internist who has taken the time to listen, assess, and get to know the whole patient. And, he has saved my life – more than once!!
Thank you Dr. Edelberg.
Valerie W
And people wonder why I don’t worry about the Mexican healthcare system if I move …
As someone who was misdiagnosed by 6 doctors for one disease and undiagnosed by 3 for another, I am, sadly, not too surprised by the diagnosis news.
Beth
Dr. E,
Reading your above post, I recalled a recent article in the Wall Street Journal titled “Capitalism Is Killing Our Morals, Our Future”. So-Called healthcare is a large part of this capitalistic drive toward armageddon. I definitely am a strong participant in capitalism. However, everything has its limits. It is about time we recognize that before it destroys any more of the U.S. than it already has. I like this country.
Mark
The diagnostic criteria requiring ‘approval’ from the insurance company to proceed to an MRI exam is fairly straight forward. The real problems are ourselves and our lawyers. If we don’t have the MRI, maybe the doctor will miss something. And in this age of legal recourse, every medical professional needs to practice ‘defensive’ medicine – even when the MRI is not clinically indicated and will most likely not provide additional information that will alter the course of treatment.
Beety M.
While in graduate school I had two roommates who were in medical school, and I believe the way we train doctors leads to their over-confidence in diagnosis. We need to rethink how we do things. The ACA is a small needed step (a marginal improvement over what we have), and just the first of many needed steps towards a functional health care system that works for all Americans.
Thanks for your insights and wisdoms. They are part of the health care you provide.
John Pearson
As a physician assistant, my brother was having an autoimmune disorder and he went to 3 physicians who all diagnosed him with a different diagnosis. He symptoms worsened. I finally saw him, made a diagnosis (in my mind) and went to two physicians with him. The first physician gave him a zebra (rare) diagnosis. which I didn’t agree with and prescribed a potent immunosuppressent medication. I asked him if I could find a more seasoned physician and he agreed. Long story short: the specialist agreed with me and the appropriate treatment was provided.
Not to brag I was correct; this really was a straight forward logical diagnosis. Frankly, I was shocked. I always ask for help or to talk with another health care provider as needed. One person just can’t know everything. Please note when my brother had an EKG at this great specialist office, I noted an abnormality (I had previously worked with abnormal heart rhythms). The cardiologist sent a report but there was no mention of the abnormality! I told the specialist of the abnormality after he was so joyful stating his EKG was normal. I pointed out the error and stated this type of work is not acceptable. He was embarrassed but agreed. As patients we all have to be on our toes!
Jeanne
Doctors’ being docked financially for seeking diagnostic help may be part of the over confidence issue. But I see a larger problem: hubris, hubris and more hubris. All of us, patients and doctors, are responsible for elevating physicians to dizzying heights of authority and respect. They have been trusted as gods and paid outrageously. We bow to their authority to the point of not trusting our own physical symptoms. We take their prescriptions despite side effects worse than the original illness. The American Medical Association’s history is a disgrace, taking money for decades from cigarette companies in exchange for denying the relation of smoking to cancer and heart disease. I’m not surprised at all by the percentage of incorrect diagnoses or by the over confidence. But it’s not all the medical profession’s fault. We all had a part in it.
Addie
As a fellow physician I am blown away by Dr Edelberg’s wisdom and ability to hit the nail on the head. This particular newsletter comes to the heart of the healthcare problems in the US. His readers may also enjoy the following TED talk by a Canadian physician, Brian Goldman
Dr Sue Zilberstein
Overconfidence is something Behavioral Economists often study and publish about. The last thing I read (in the Motley Fool) started out with “this article isn’t about the mistakes others make, it’s about the mistakes you and I make.”
Mark Evans
Misdiagnosis by doctors is not at all a surprise. I hear this all the time, and I also have a personal story of my mother. She had gas pains, bloating and cramps for six months and her doctor told her it was some kind of gastroenteritis problem and gave her a prescription/pills for it. Within 6 months, she died of ovarian cancer, which had spread to the liver, etc. He never requested further tests nor referred her to a specialist. This happened in a small doctor’s office in Casa Grande, AZ, and I’m betting this happens even more often than you imagine in a small town office.
Chris Moses
What wonderful holiday news, especially since we just sent in our enrollment form to join the Medicare Advantage United Health Care PPO plan. We did not have much choice, seeing as how we are in a group under the TRS system. So glad that Dan’s heart surgery is behind him already. Happy Thanksgiving to you and yours.
Mery Krause