April 26, 2018
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Sometimes doctors don’t know best

By Kathy Pollard, Special to the BDN

Dr. Erik Steele’s Feb. 14 article “Is it nothing or could it kill you?” revealed troubling considerations clinicians face in the practice of medicine.

Health care is shifting to a business model, and money matters. Steele stopped short of saying what can happen if a patient has inadequate resources to pay for care. He likened the diagnostic process to walking a tightrope. By taking a “wait-and-see” approach, many symptoms abate on their own without costly procedures. But if the symptoms portends a life-threatening condition not adequately investigated, the patient can die.

This article hit a still-raw nerve. In 2006, my brother, 34, experienced off-the-charts abdominal, chest, neck, jaw, tooth and arm pain. He sought evaluation immediately at a hospital emergency room. After writhing in agony for about six hours — pain not lessened by shots of narcotic analgesics — he was discharged with an inaccurate diagnosis.

A few hours later — while trying to get the words out to answer his 5-year-old daughter’s query, “Are you feeling any better, Papa?” — he collapsed before her eyes and was gone. Not suffering from “constipation,” as the provider insisted despite my brother’s protest, he died of an ascending aortic dissection — a condition that cannot be survived without surgical repair.

After the funeral, my 2-year-old nephew looked up at me and said with a poignancy I will never forget, “My papa … died.” My own heart, already cracked with grief, shattered as I struggled to remain composed for this little one, who would grow up unable to recall the father who would not have abandoned him or his sister for any force on earth — could he but stay.

My brother’s story underscores the very human element in those cases that the institution of medicine relegates to the category of medical “error.” Like most people, he was conditioned to believe that when frightening symptoms arise, doctors will do everything possible to find the cause. But when patients are evaluated, many variables factor into the medical decision making process without patients’ awareness.

Consider this: What if a patient with “state” insurance — or no insurance at all — was presented with my brother’s symptoms. Would he or she receive different care from someone with Blue Cross insurance, which reimburses at a higher rate? I would say yes. Put differently, what if the patient was a health care CEO? Would he or she have been discharged with a diagnosis of constipation? I would say no.

Many other variables influence the diagnostic process, including the inherent limitations of the clinician’s memory, provider bias and attention span. A visionary physician, Dr. Lawrence Weed, recognized these pitfalls, and at a time when computers were in their infancy, he saw their promise as a ballast. He developed a triage-like system called Problem Knowledge Couplers, now a part of Sharecare.com, for fleshing out symptoms and pairing them with the most likely diagnoses. PKC is a pattern recognition tool that can greatly enhance patient care. Yet, despite this, it is not widely employed.

Steele did not mention this technology when he spoke of the tightrope walk providers embark on during the diagnostic process. One has to wonder why. Why wouldn’t risk managers, malpractice liability insurance carriers, hospital administrators and medical providers alike jump at the opportunity to use a diagnostic tool that could reduce the incidence of error, misdiagnosis and untimely death?

Part of the answer may be somewhere between the lines of what Steele alluded to. If black and white evidence (provided by the PKC) existed of an ignored, potentially life-threatening condition, it would subvert the current discretionary leeway in medical decision making.

Recently my family lost our father. As he was breathing his last, my sister said, “When you see Bob, dad, give him a big hug for us, and tell him how very much we love and miss him!”

Clinicians and hospital administrators, may our loss be your gain of renewed commitment and compassion as you navigate the ever more complex variables — that proverbial tightrope walk — that factor into your provision of care for patients who entrust their lives to you.

And patients, beware. What the doctor tells you may not be accurate. Trust your instincts; verbalize your dissent; seek another opinion. And get on board with technology you’ll soon have at your fingertips. The PKC system — renamed AskMD — will soon be available for free from Sharecare.com, both on their website and as a free iPhone download. Had it been used in my brother’s case, he would likely still be alive today.

Above all, don’t just cave in to the old adage, “doctor knows best,” because that may be your last chance to take a stand.

Kathy Pollard, of Orono, was a clinical assistant at Dr. Charles Burger’s Bangor-based Evergreen Woods Internal Medicine Practice, now Martin’s Point, where the PKC is used in every patient encounter.

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