Tuesday, October 18, 2011

Diagnostic skepticism---a victim of competing interests

When I first read this post by Dr. Robert Centor at DB's Medical Rants about diagnostic skepticism I wondered why anyone would need to write about such a no-brainer. After all, rigorous skepticism is ingrained in us as physicians, right? But as I thought about it I realized that skepticism is lacking from day to day practice. As a hospitalist (and I'm sure this is true for other physicians) I have observed many things that conspire against diagnostic skepticism. These include the pressures of time, the performance movement and other competing interests as well as even the electronic medical record.

Some of the performance measures, particularly those that are time dependent, may cause the clinician to rush to a diagnosis. How many patients in the ER, for example, have been inappropriately diagnosed as pneumonia because the physician was in a rush to satisfy the time-to-antibiotic performance metric? How many patients with chest pain and ST elevation have been inappropriately rushed to the cath lab with pericarditis or even benign early repolarization because of the pressure of door-to-balloon time? Diagnostic skepticism does take time. Time to think.

Time pressures may also be driven by a variety of other administrative agendas. With all the emphasis today on rapid ER throughput, for example, patients need a quick diagnostic label as their ticket to get them admitted in a timely manner. These labels are administratively important but may lead to incorrect diagnoses. Other competing interests are about money, such as “clinical documentation” and DRG coding.

The EMR itself may enable inappropriate diagnosis and undermine diagnostic skepticism in a number of ways. Electronically generated problem lists and note templates are tied to the decades-obsolete ICD-9 codes. You can always free text the patient's real diagnosis but it's more often the electronically generated garbage that will be forwarded from note to note over time thus perpetuating inappropriate diagnosis. So in order to employ diagnostic skepticism you have to sit down and think. Not only that but you may have to undo some of the electronic garbage generated by the EMR. It all takes time. Time that hospitalists all too often don't have.

It's all made worse by the conflicting incentives. As a hospitalist, for example, what are some of the metrics you are held to? ER throughput, discharge time, patient satisfaction, coding and length of stay to name a few. These all take time away from diagnostic skepticism. Hospitalists are not incentivized for their diagnostic skills.

Our hospitalist leaders (except of course for Dr. Centor) are not helping matters. Take a look at the Society of Hospital Medicine website. There are some great resources there but almost all of them are about system and administrative issues in hospital medicine. There is no focus on diagnostic skills.

So the notion of diagnostic skepticism is very simple. All you have to do is stop and think. Take a moment to consider whether the diagnostic label perpetuated by the EMR is really true. Who knows, you may experience a Dr. House moment. You may even save a life.

1 comment:

james gaulte said...

Bravo,every thing you said really needs to be said.