Is Poor Diagnosis a Leading Cause of Inefficiency in the Health System?

Much of the load on the health system is the consequence of the poor performance of current diagnosis processes.  Of GPs who think that their instinct is better than it actually is.  Of wild stabs in the dark based on prejudice, assumption and the couple of questions that GPs have time to ask in a six minute appointment.  Yes, I know that some things are hard to diagnose.  But for God’s sake, we have to get better at this if our health systems are going to survive…

 

I’m currently on “holiday” in the UK for a couple of months with my family, hence the lack of blog articles in the last few weeks.  For part of the time we’ve been staying with my parents, who are now in their seventies.

Over the last few months, mum has felt the gradual development of a numbness in the fingers of her left hand and her wrist.  In the last two weeks this has quickly escalated and her wrist and fingers have become inflamed, extremely painful and difficult to move.  The same symptoms have developed in the right hand / wrist in the last 48 hours.

But let me take you back a couple of weeks…

For all my mother’s wonderful strengths, she’s mightily stubborn, having been raised in a generation that “just gets on with it”.  She’s not one to go to the doctor easily, and that stubbornness isn’t helped by the fact that it can take 2-3 weeks to get an appointment with a GP in her town.

Anyway, just over a week ago she finally admitted that she needed help, and managed to get the GP to “squeeze her in”.  (I love the way that patients are often made to feel like they are inconveniencing the doctor!).  Despite my mother describing a history of carpal tunnel syndrome in the other (right) wrist, the GP, without asking any questions, told her categorically that it “couldn’t be carpal tunnel syndrome”, and “was probably gout”.  He gave her a prescription for an NSAID, a blood test order (although told her that she couldn’t actually have the blood test for another 10 days) and showed her out.

A few days later the pain escalated significantly to the point where mum was in tears.  Dad called 111, the NHS number for non-emergencies, particularly during out-of-hours.  After a first phone call, explaining the problem twice to two different people, waiting nearly two hours for a callback that never happened, calling up and going through the process again, mum finally spoke to a doctor.  He said that he could send somebody out, but it would probably be at least three hours and that he couldn’t guarantee that they could help her anyway.  Mum gave up and, in much pain, tried to get some sleep.

The next morning my dad went to the GP surgery in person and demanded that mum see a doctor.  I’m sure it didn’t go down well, but he secured an appointment for that morning.  This time, a different GP wasn’t able to make a diagnosis, but prescribed a codeine-based opiate for the pain and (magically) ordered an immediate blood test from the practice nurse.  A follow up phone call from the GP confirmed that it isn’t gout, but that there is “inflammation”.  Thanks for that.

And this is where we find ourselves.  Mum awaiting a follow up GP appointment tomorrow to get the results of the blood test.  Now on opiates and NSAIDs, mum is no closer to a diagnosis, and I suspect she will simply be told tomorrow that she has “inflammation, but we’re not sure what is causing it”.  We’ll see…

 

So many things about the health system make me angry, but this undoubtedly everyday example shines a light on some of the worst elements of our broken health system(s):

  • Medical paternalism at its worst – The arrogance of pronouncing a likely diagnosis (which turned out to be wrong), whilst ignoring the patient’s stated personal history of related conditions and asking a sum total of zero questions to the patient.  I wish this was unusual.  In what other professions could someone behave this way without being fired?
  • The mediaeval nature of our approach to diagnosis – Perhaps you, readers, can help me with this…  I want to understand how medical professionals, particularly GPs / Primary Care Physicians approach the science of diagnosis?  Is diagnosis a science?  How do you overcome your own personal biases – socio-economic, demographic, racial, gender, when making a diagnosis?  How do you avoid falling victim to confirmation bias?  I think many of us patients resort to using online information and Digital Health Communities to assist with diagnosis precisely because the process of diagnosis we get from our GPs feels so unscientific.  Unless this changes then I believe that a time is coming when many (but not all) GPs should be replaced with a more rigorous process of diagnosis.  Potentially one that leverages Artificial Intelligence.
  • The huge inefficiency caused by poor diagnosis – Just stop for a moment and think of the consequences of poor diagnosis.  If we were able to diagnose conditions (and their underlying root causes) faster, then we’d see a huge reduction in demand for health services.  Much of the load on the health system is the consequence of the poor performance of current diagnosis processes.  Of GPs who think that their instinct is better than it actually is.  Of wild stabs in the dark based on prejudice, assumption and the couple of questions that GPs have time to ask in a six minute appointment.  Yes, I know that some things are hard to diagnose.  But for God’s sake, we have to get better at this if our health systems are going to survive…

 

2 Responses to“Is Poor Diagnosis a Leading Cause of Inefficiency in the Health System?”

  1. Sharon
    June 4, 2017 at 12:35 pm #

    How do you overcome your own personal biases – socio-economic, demographic, racial, gender, when making a diagnosis?

    Great question. What a fantastic forum topic or PD session.

  2. William G Hartwell
    November 5, 2017 at 10:43 pm #

    In my experience, especially if you have a chronic illness, the first thing your GP does is attempt to refer you to whatever mental health practice is associated with your insurance plan.

    As an example, my wife has Ehlers-Danlos Syndrome, with signs of both hypermobility and vascular forms. At every appointment, our GP attempts to convince her that her pain and cardiac symptoms are all due to her “anxiety”. She has to remind him that she has been diagnosed with EDS, and that she has a history of lab results showing MVP, elevated CRP, and other things associated with EDS.

    Our pain management specialist, who is NOT an EDS expert, has bothered to do enough research to know that multiple daily subluxions, cardiac problems, and constant inflammation from soft tissue damage, requires treatment that, unfortunately, he cannot prescribe because it has to go through our GP to be approved. The best he can do is prescribe a low-dose maintenance pain regimen with breakthrough meds for when she dislocates something.

    Meanwhile, the GP continues to claim all her problems are due to “anxiety”.

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