Diagnosis takes a back seat under administrative pressures

A pithy little note over at DB's Medical Rants got me thinking. From the post:

Diagnosis generally dominates the first few admission days. We cannot really develop a good treatment plan until we solve the diagnostic dilemma.

I agree. But given typical lengths of stay of three or four days that means the majority time spent in the hospital should be devoted to just getting the right diagnosis for many patients. Worse, a significant number will leave the hospital without being correctly diagnosed at all.

But today's external pressures drive us in another direction, which is to force a diagnostic label on the patient too early. First the emergency physician is pressured to label the patient in order to convince the hospitalist to accept the patient for admission. Then the hospitalist has to assign a “principle problem.” If the problem statement is vague (such as a symptom), as is often appropriate, pressure comes from the coding and quality people to make the diagnosis more specific and get the patient on a care pathway. The performance incentives that follow are meaningless if the resulting diagnosis is incorrect.

Dr. Lawrence Weed, originator of the problem oriented medical record, appreciated this fact decades ago when he gave us this rule: in stating the patient's problem do not go beyond the level or resolution you have at the time. If that means listing the problem as “funny looking EKG” so state it until further data and expertise become available.