Doctors overestimate risk leading to over-diagnosis, overtreatment, study finds

by University of Maryland School of Medicine

Credit: CC0 Public Domain

Primary care practitioners often over-estimate the likelihood of a patient having a medical condition based on reported symptoms and laboratory test results. Such overestimations can lead to overdiagnosis and overtreatment, according to a recent study conducted by researchers at the University of Maryland School of Medicine (UMSOM) published in JAMA Internal Medicine.

03 may 2021--"A large gap exists between practitioner estimates and scientific estimates of the probability of disease," said study leader Daniel Morgan, MD, a Professor of Epidemiology & Public Health at UMSOM. "Practitioners who overestimate the probability of disease might use that overestimation when deciding whether to initiate therapy, which could lead to the overuse of risky medications and procedures."

To conduct the study, Dr. Morgan and his colleagues surveyed 553 primary health practitioners, including residents, attending physicians, nurse practitioners and physician assistants, in Maryland and seven other states. Survey respondents were asked to determine how well they could estimate the risk of four well-known health conditions based on hypothetical diagnostic scenarios. The researchers found, based on symptoms and test results, that health care providers significantly overestimated the likelihood of conditions. For example, health care providers, on average, estimated a 70 percent likelihood of cardiac ischemia in patients who had a positive finding on a stress test. In reality, based on evidence from medical studies, the real likelihood of cardiac ischemia is 2 to 11 percent.

The study also found that survey respondents estimated a 50 percent risk of breast cancer after a positive finding on a mammogram when evidence suggests 3 to 9 percent chance of breast cancer. They estimated an 80 percent likelihood of a urinary tract infection from a positive urine culture, and the vast majority of survey respondents said they would treat with antibiotics in these cases. The real risk of a UTI with a positive urine culture, however, is at most 8 percent.

"Solving this problem is not about asking health care providers to memorize numbers or practice math in order to improve their understanding of risks," Dr. Morgan said. "We should, however, use probability and better utilization of decision-making tools to help them make better estimates."

He developed a free tool called Testing Wisely, funded by the National Institutes of Health, that is designed to improve clinician understanding and ordering of diagnostic tests to make patient care safer. The site also includes a risk calculator to assess patients' symptoms, exposure, and local positivity rates where they live to calculate their individual risk of having COVID-19.

"Informed medical decision-making is incredibly important, and physicians should have access to tools that make their job easier and improve patient safety," said E. Albert Reece, MD, Ph.D., MBA, Executive Vice President for Medical Affairs, UM Baltimore, and the John Z. and Akiko K. Bowers Distinguished Professor and Dean, University of Maryland School of Medicine. "This study demonstrates the need for better decision-making tools to help healthcare providers provide the best possible care to their patients."

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More information: Daniel J. Morgan et al, Accuracy of Practitioner Estimates of Probability of Diagnosis Before and After Testing, JAMA Internal Medicine (2021). DOI: 10.1001/jamainternmed.2021.0269

Provided by University of Maryland School of Medicine 

Confusing Confusion

By LISA SANDERS, M.D.
07 dec 2008
1. SYMPTOMS
The middle-aged man writhed on the gurney in the E.R. His eyes were squeezed shut. Low moans emerged from his parched lips. His sister and brother — the only members of his large Polynesian family who lived here in Portland, Ore. — tried to comfort him, but worry was etched deeply into their faces. Dr. David Peel, the emergency-room doctor at Providence Portland Medical Center, was also worried. This 53-year-old man had a fever and excruciating pain in his back. One leg was weak and he was confused. But the scariest part of all was that the man had been discharged from this hospital just three days earlier after being treated for the exact same thing.
Peel quickly reviewed the records of that first weeklong stay in the hospital. The patient, a smoker, had a history of diabetes and high blood pressure. He came in confused and with a fever. During that admission, the medical team thought he had an infection in his brain, an encephalitis. His white-blood-cell count was high, which was consistent with an infection, and his spinal fluid was abnormal, suggesting inflammation. In addition, the amount of sodium in his blood — an essential mineral and one that is tightly regulated by the brain and the kidneys — was dangerously low, a condition known as hyponatremia. Infections can cause low sodium. So can severe vomiting and diarrhea. And both the encephalitis and the hyponatremia can cause confusion. The team put the patient on powerful antibiotics and was replacing the missing sodium. Treat both, the doctors thought, and the confusion should improve. But it didn’t. His fever went down; his sodium went up. But his confusion remained unchanged. He still didn’t know where he was or why he was there.
2. INVESTIGATION
That’s when the team consulted Dr. David Gilbert, one of the most respected infectious disease doctors in the area. Gilbert talked with the patient’s family about the days and weeks before the man came to the hospital. A month earlier, the three siblings traveled to California, where the rest of their large extended family lived, for their annual luau. A few days after returning, their brother started to complain about a pain in his back. They weren’t sure if he hurt it at the party or on the job — he was a mason — but the pain quickly became severe enough to keep him out of work. He also complained of some nausea and diarrhea. He told them he felt weak, tired. And then, suddenly, he stopped making sense. His speech became slurred and rambling. That’s when they took him to the hospital.
Gilbert agreed this was probably an infection in the brain. They had looked for the most common causes of encephalitis — like herpes — without success, so Gilbert suggested they look for some of the more unusual infectious agents. Enterovirus was a common cause of nausea and vomiting and sometimes encephalitis. And the patient had recently been to California, so California encephalitis, an unusual mosquito-borne infection, was a possibility. But Gilbert was most concerned about a different mosquito-borne infection, the West Nile virus, which had been moving westward since its first epidemic in New York City in 1999. Two weeks earlier, two birds tested positive for the virus on the outskirts of Portland. Could this patient be the first case of the season?
They would need to look for each of these viruses in the spinal fluid. And they should stop all the antibiotics he was now getting. If he had a virus, they wouldn’t help. If he had a bacterial infection, the antibioitcs would make finding it even more difficult, and identifying the bug was essential to ensuring the infection was properly treated.
And then they waited. Five days later, the patient started making sense: he was able to tell the team that he was in the hospital, and he knew what year it was. The family was ecstatic. The doctors still didn’t know what he had, but they were relieved that he was getting better. A couple of days later, he was still a little confused, but his family persuaded the doctors to send him home.
But now, just three days after his discharge, he had returned. His back pain was excruciating and radiated down his left leg, making it too painful to move. He had a fever. His sodium was even lower than it was a week earlier. His white-blood-cell count was high, and his red-blood-cell count, which had been normal, had dropped precipitously. All the tests sent out during his last hospital stay came back negative. He was deathly ill, but it was clear to Peel that no one had any idea why.
The combination of fever, back pain and weakness worried Peel. Perhaps the infection was in his spinal column. He sent the patient to get an M.R.I. The radiologist called as soon as the scan was done. There was no abscess on the spinal cord, but the patient’s aorta had weakened and the pressure of the blood flow had caused the tube to bulge like a worn garden hose. He was also concerned that this weak spot had sprung a leak. He could see blood outside the vessel.
This was an emergency. A ruptured aorta, even when it happens in the hospital, has a mortality rate of 50 percent. Peel called the vascular surgeon, and the patient was rushed to the operating room.
The left side of his abdominal cavity was filled with blood, and parts of the normally thick tube of the aorta were in tatters. The surgeon quickly replaced the shredded portion of the aorta and sent the dissected bits to the lab. Under the microscope, it became clear what had caused all of this man’s symptoms. The tissue had been invaded by a bacterium — an unusual type of salmonella, one usually found in uncooked pork. This bug — salmonella choleraesuis (from Latin, meaning the gut of the pig) — had wreaked havoc. Like the more familiar salmonella infection, picked up from eggs and other contaminated foods, this one causes nausea, vomiting and diarrhea. But salmonella can do much much more: under the right circumstances, it can get out of the digestive system and invade virtually any part of the body. This type of salmonella has a particular affinity for the blood vessels. It had invaded the patient’s aorta and clouded his brain.
3. RESOLUTION
The brief dose of antibiotics during his first hospital stay had tamed the infection temporarily — that’s why he was able to go home — but the extensive destruction of the aorta made a lengthy course of antibiotics and the surgical repair imperative. With the infective agent finally identified, the patient was started again on antibiotics.
When David Gilbert came into the hospital the next morning, he was surprised to find that his patient from a few days before was again listed among the patients in the I.C.U. and even more surprised to see what had made the man so sick.
He sought out the family. Did they have any idea where this man may have been exposed to uncooked or undercooked pork? And why hadn’t anyone else gotten sick? That was easy, the sister told him. The patient always prepared the pig for the family luau. It was his specialty, and no one else was allowed to touch, much less taste, the meat until he served it.
With the infection under control, the patient recovered rapidly. Three days after the operation, Gilbert found him sitting up in bed, laughing and chatting with his family. This year, his family skipped the roasted pig at the luau, the patient told me recently. Maybe next year they’ll try again. Or maybe not.

Patients use internet to challenge doctors

One fifth of patients are challenging their doctors' advice or diagnosis using knowledge gained from the internet, a survey suggests.
The survey, conducted for the Southern Cross Medical Care Society, showed 73 per cent used the internet for health information and one in five take the information with them when they see their GP.
Twenty two per cent used information from the internet to challenge their doctor despite one per cent of respondents saying they trusted the information on the web.
Southern Cross chief executive, Dr Ian McPherson, a former GP, said he had mixed feelings on these statistics.
"On one hand it's concerning that people making their own diagnosis could be getting it very wrong.
"On the other hand it's a positive sign that people are increasingly proactive about their health and are prepared to look for information which helps them have a constructive and more informed discussion with their GP.
"They are more likely to go to the doctor better prepared with questions."
Dr McPherson said there was no harm in challenging a medical opinion, but he cautioned people not to put too much faith in the internet to self-diagnose.

Forgetting Everything

By LISA SANDERS, M.D.
1. Symptoms
The flashing icon announced that an instant message had arrived. The young woman at her computer at work clicked on it eagerly. It was from her fiancé. Silly boy. She’d only left him an hour ago.
“Something’s wrong,” the message read.
“What do you mean?” she shot back.
“I can’t remember anything,” he wrote. “Like I can’t tell you what we did this weekend.”
The young woman’s heart began to race. Her fiancé had been strangely forgetful lately. She thought maybe he was just tired. He’d been having trouble sleeping for a couple months — ever since they’d moved in together. The previous weekend they went to New York to plan their wedding. He had been excited when they set up the trip, but once there he seemed unusually quiet and hesitant.
“When is our wedding date?” she quizzed. “Can you tell me that?”
“No :(”
“Call the doctor. Do it now. Tell them this is an emergency.”
Over the next half-hour the 27-year-old man put in three calls to his doctor’s office, but each time, he would forget what they told him by the time he messaged his fiancée. Separated by miles of Interstate and several suburbs, the young woman was frantic. Finally, at her insistence, the man, now terrified, asked a friend to take him to the closest hospital.
A few hours later, her cellphone rang. At last. He was being discharged, he told her. The emergency-room doctor thought his memory problems were caused by Ambien, the sleeping pill he was taking. The doctor said the symptoms would probably improve if he stopped taking the medication. Probably.
“Don’t go anywhere,” the young woman instructed. “I’ll pick you up. I’m going to take you to your doctor.” She found him wandering the street near the hospital, uncertain about why he was there and even what her name was. She hustled him into the car and drove to his doctor’s office. From there they were sent to Brigham and Women’s Hospital in Boston.
2. Investigation
Late that night, the on-call resident phoned Dr. William Abend at home to discuss the newest admission. Abend, a 61-year-old neurologist, scrolled through the patient’s electronic medical record as the resident described the case. The patient, who had no history of any previous illnesses, had come in complaining of insomnia and severe memory loss. Psych had seen him — he wasn’t mentally ill. His physical exam was normal except he didn’t know the date and couldn’t recall the events of the week or even that day. The E.R. had ordered an M.R.I.
The patient needed a spinal tap, Abend instructed, to make sure this wasn’t an infection and an EEG to see if he was having seizures. Both could affect memory — though this man’s memory loss sounded pretty profound.
The next day the patient was alert and anxious when Abend came to see him. Tall and slender with earnest blue eyes, he seemed embarrassed by all that he couldn’t remember. His fiancée had gone to get some rest, and so his mother provided details. He first complained about some memory problems a couple of months earlier. The past weekend everything got much worse. Overnight, he kept forgetting he was in the hospital and repeatedly pulled out his IV.
On exam, Abend found nothing out of the ordinary save the remarkable degree of short-term memory loss. When Abend asked the patient to remember three words — automobile, tank and jealous — the patient could repeat them but 30 seconds later he could not recall even one. “It wasn’t like — where did I put my car keys?” Abend told me later. “He really couldn’t remember anything.” The neurologist knew he had to determine what was going on quickly, before further damage was done.
Abend checked the results of the spinal tap — no signs of bacterial infection. Then he headed over to review the M.R.I. images with Dr. Geoffrey Young, the neuroradiologist. The patient’s brain, Young told him, showed no evidence of a tumor, stroke or bleeding. What the M.R.I. revealed were areas that appeared bright white in the normally uniform gray of the temporal lobe on both sides of the brain.
There were only a few diseases that would cause this kind of injury, Young told him. Viral encephalitis — an infection of the brain that can be caused by herpes simplex — was certainly the most common. Autoimmune diseases like lupus, Young continued, could also cause these kinds of abnormalities. In lupus, the body’s natural defenses mistakenly attack its own cells as if they were foreign invaders. Finally, added Young, certain cancers can do this, too — it’s usually lung cancer; usually in older smokers.
The job of a radiologist in a case like this is to identify the abnormality in the imaging and outline the possible causes. The patient’s doctor must then weigh the likelihood of each disease, based on what he knows of the patient. In this case, the young man’s symptoms had been coming on gradually over two months. Abend thought that made an infection like herpes less likely. The patient had already been started on acyclovir — the drug usually used to treat this virus, since it can be deadly when it infects the brain. They would need to do additional tests of the spinal fluid to make sure there was no evidence of this viral infection.
Lupus seemed even more unlikely to Abend. It is a chronic disease that can attack virtually any organ in the body and is generally characterized by joint pains and rashes. The patient had none of these symptoms. Still, perhaps this was the first sign of this complex disease. It would be unusual, but so was the young man’s extensive memory loss.
Although cancer was an uncommon cause of this kind of injury, it seemed to Abend the most credible in this patient. Even nonsmokers can get lung cancer. And other cancers can cause the same type of brain injury. Moreover, if these symptoms were caused by a cancer, there was a good chance that they would resolve once the cancer was treated. He ordered what is sometimes called a “whole-man body scan,” a C.T. of the chest, abdomen and pelvis. They needed to look everywhere. They didn’t have time to be wrong.
3. Resolution
Results from the tests trickled in over the next few days. He wasn’t having seizures. It wasn’t a virus. He didn’t have lupus. But by the time those test results arrived they already had an answer. The C.T. of the chest had shown a large mass — not in his lungs, but in the space between them, the area called the mediastinum. A biopsy revealed the final diagnosis — Hodgkin’s lymphoma — a cancer that attacks the immune system. He had what is called a paraneoplastic syndrome, a rare complication in which antibodies to his cancer attacked healthy cells in his brain.
The patient had surgery to reduce the size of the mass and started chemotherapy. Slowly, his memory began to improve.
But even now, almost four months later, the trip to New York remains vague, and his only memory of his week-long hospital stay is his nurse telling him he was going home. His fiancée remembers the day she realized he was getting better. It was several weeks after leaving the hospital. She reminded him that he wanted to get a haircut. He told her that he tried to go the day before but the line at the barbershop was too long.
She almost cried. “At that moment,” she told me, “I finally knew that the man I loved was still in there and that he was coming back.”

10 overused tests and treatments

1BACK SURGERY. Don't rush to surgery for a simple slipped disk. In 90 percent of cases, the pain goes away on its own within six weeks. In stubborn cases, surgery, which can cost $20,000 plus physician's fees, can relieve pain somewhat faster than physical therapy and medication, a recent study showed. But it also found that both groups of patients wound up with similar improvements after two years.
2HEARTBURN SURGERY. Doctors surgically tighten a sphincter muscle that blocks stomach acid from backing up into the esophagus. But research shows the operation, which costs $14,600 or more, provides no better long-term relief than taking a proton-pump-inhibitor drug such as omeprazole (Prilosec OTC), which costs less than $1 a day.
3PROSTATE TREATMENTS. Prostate cancer is often overtreated by surgery that costs $17,000, or by radiation therapy for $20,700 or more, plus physician's fees, without adequate discussion of the alternatives or the high risk of distressing side effects such as incontinence or impotence. Because prostate cancer can grow slowly, sometimes the best approach is "watchful waiting."
4IMPLANTED DEFIBRILLATORS. These devices, which automatically shock the heart back to normal rhythm, cost some $90,000 over a lifetime. Yet one-third of people who get them might not really need them, according to research reported in 2007. This year Medicare will pay for an estimated 50,000 of the devices.
5CORONARY STENTS. Billions are spent each year inserting tiny mesh tubes to prop open coronary arteries. The procedure plus heart drugs turns out not to work any better to prevent future heart attacks than heart drugs alone for patients with stable coronary artery disease, researchers reported in 2007.
6CESAREAN SECTIONS. They cost almost $7,000, about 55 percent more than a natural delivery, and constituted a record high of 30.2 percent of births in 2005. Most are performed because labor is progressing too slowly. But several less-invasive approaches might be enough to speed up labor.
7WHOLE-BODY SCREENS. These CT scans, which can cost $1,000 or more, are promoted for spotting early signs of cancer, heart disease, and other abnormalities. There are no proven benefits for healthy people, the Food and Drug Administration has concluded. Plus CT scans expose patients to far more radiation than X-rays. A few CT scans a year can increase your lifetime risk of cancer.
8HIGH-TECH ANGIOGRAPHY. Using a CT scan to noninvasively check coronary arteries for narrowing costs an average of $450, according to data from HealthMarkets, which sells health and life insurance through subsidiaries in 44 states. But standard angiography is sometimes still needed to confirm blockages that might require aggressive treatment.
9HIGH-TECH MAMMOGRAPHY. Using software to flag suspicious breast X-rays would add $550 million a year to national costs if used for all mammograms. But a 2007 study found that this technique failed to improve the cancer-detection rate significantly, yet resulted in more needless biopsies.
10VIRTUAL COLONOSCOPY. These CT scans are being used to detect signs of cancer without inserting a tube into the colon. But a study of virtual colonoscopy reported in 2007 concluded that standard colonoscopy is better at spotting smaller suspicious polyps. Though less costly than a standard colonoscopy, the virtual test isn't cost-effective because any suspicious finding requires retesting with the real thing.

Diagnostic Errors
By Internists Often
Go Unrecognized

In one case that was included in the study of
diagnostic errors, an elderly man with endstage
chronic obstructive pulmonary disease
(COPD) was admitted to the emergency department
at 1:00 a.m. for midabdominal pain
and a hematocrit that had declined from a
baseline of 36% to 29%. The patient was on 60
mg prednisone for the COPD.
Although he was delirious from pain, the
man related a history of a bleeding peptic ulcer
some months earlier with similar pain.
Upon examination he was confused, with mild
abdominal tenderness. His stool was negative
for occult blood, and a nasogastric tube could
not be passed.
“The clinicians who saw him in the emergency
room weren’t quite sure what was going
on, but their No. 1 impression was that the patient
had a recurrence of his peptic ulcer,” Dr.
Graber said.
When the patient was seen 6 hours later by
the ICU attending physician, there was no evidence
of melena or hematemesis, but the man
was now in shock. The attending physician
considered the possibility that the patient had
dissection of an aortic aneurysm. A 6-cm dissecting
aneurysm was confirmed by CT scan,
but the patient died in the radiology suite.
“An investigation found that the team had
not read through the patient’s old chart—nor
was it available—and had not contacted the patient’s
primary care physician,” Dr. Graber
said. “Either one of these sources would have
quickly told the story. The patient had a
known abdominal aneurysm.”
The data collection by the medical team
“was grossly incomplete,” he said. “The synthesis
of information was faulty. They had the
wrong context. They had never considered the
possibility of aneurysm. They were thinking
GI causes.”
As for the system errors in this case, “clearly
the lack of medical records was a problem,” Dr.
Graber said. “So was the culture of the organization.
How could someone in the emergency
department feel comfortable taking care of this
patient without seeing his old records or without
talking to his primary care provider?”

Missed Signals

1. Symptoms
The emergency technicians burst through the doors, pushing a stretcher into the crowded E.R. Their walkie-talkies dangled from their shoulders, squawking and hissing like demented parrots. The triage nurse directed them straight into a room as the E.M.T.’s barked out what they knew. “Sixty-four-year-old man . . . history of a stroke . . . complaints of weakness and belly pain.” His heart was slow, they reported; his blood pressure so low that it was immeasurable. The monitor showed a heart rate in the 20s — normal is over 60. Dr. Bernd Woerner strode in and quickly assessed the situation. “Get me an amp of atropine,” he snapped, calling for the medicine used to speed up the heart.
The doctor watched as the monitor screen continued its flat yellow line, broken only occasionally by the spike indicating another heartbeat. Slowly the patient’s heart rate and blood pressure began to rise.
Throughout all this the patient was alert, Woerner told me later. He explained to the patient, “Your heart is pumping too slowly.” The medicine would keep his heart rate up until the cardiologist arrived in an hour or so to insert a pacemaker. In the meantime, they had to begin to figure out what was wrong with his heart.
I knew this patient. I was his internist and had been seeing him for the past year, since he had his stroke. Before that, he hadn’t been to a doctor for decades. He came to me when the massive stroke rendered his right leg and arm nearly motionless, his face crooked and his speech slurred. Still, his beautiful cockeyed smile and gallant manner made him a favorite at our office. He often brought us gifts — candy or some of the pecans sent from his family in North Carolina. He was doing well, so I was shocked when I got word from the E.R. that my patient was dying. And the doctors there weren’t sure why.
With the usual chaos of the emergency room boiling around them, Woerner forced himself to sit quietly as the patient described his symptoms. The man spoke in an unnaturally deliberate drawl, as if in slow motion: “I — can’t — walk.” It started the night before. He felt weak, could barely move. Any chest pain? Woerner broke in. Shortness of breath? Fever or chills? Vomiting? The patient shook his head no. He was taking medications to lower his blood pressure and cholesterol. He had not smoked or drunk alcohol since his stroke. Examining him, Woerner saw the results of the stroke but little more.
2. Investigation
Why was his heart beating so slowly? the doctor wondered. Had he taken too much of one of his medications? Had he suffered a heart attack that affected the natural pacemaker in his heart?
Part of the answer came less than an hour later. The lab called to report that the patient’s kidneys weren’t working. And his potassium — an essential element in body chemistry, regulated by the kidneys — was dangerously high. Potassium controls how easily a cell responds to the body’s commands. Too little potassium, and the cells overreact to any stimulation; too much, and the body slows down. The patient was given a medicine to get the potassium out of his system and then transferred to the I.C.U. for monitoring.
If the potassium was high because of his kidney failure, what had caused his kidneys to fail? Dr. Perry Smith, the intern on call in the I.C.U., gnawed at this question as he reviewed the chart and examined the patient. It wasn’t a drug error. The patient’s medication box showed the correct number of pills. And it hadn’t been a heart attack; a blood test proved that. Smith looked for the results of the urinalysis to see if there was any clue there. Somehow no one had sent any urine to the lab. Were his kidneys too damaged to produce urine? That would be important to know. Smith asked the nurse to get some urine from the patient.
She returned empty-handed. The patient couldn’t urinate, and she hadn’t been able to insert a Foley catheter, a rubber tube that is passed through the urethra into the bladder to collect urine. Was something blocking the urethra? A urology resident finally managed to get a catheter into the bladder. Urine gushed out — nearly half a gallon of it. A full bladder normally holds only a quarter of that. The urology resident looked at the intern: “I guess now we know why his kidneys weren’t working.”
3. Resolution
The urethra was blocked — by the prostate gland. The prostate surrounds the urethra, and when it enlarges, as it often does with age, it impinges on the narrow outlet, obstructing and ultimately blocking it so that no urine can pass. As the trapped liquid filled the bladder, the pressure shut down the patient’s kidneys.
Just hours after the obstruction was relieved, his potassium began to drop as the kidneys went back to work. Four hours later, the patient’s heart rate was up over 60. By the next morning, the abdominal pain, probably caused by his hugely distended bladder, had eased. When he left the hospital three days later, his potassium and heart rate were normal and his kidneys, nearly so. He would have to keep the tube in his bladder until his prostate could be removed.
I was out of town that first day and had to follow my patient’s progress by telephone. When I heard that the prostate was the cause of the life-threatening bradycardia, I felt as if I had been punched in the chest. This was something I should have caught and didn’t. An internist’s job is to diagnose and treat acute illness and screen for and prevent additional disease. I joke with the residents I teach that it is our responsibility to keep our patients healthy and out of the hospital. If so, I had failed.
Screening for disease has two parts: usually a physical exam and what is known as a review of systems, a set of questions used to elicit symptoms of a disease the patient is at risk for. This patient, with his high blood pressure, high cholesterol and stroke, would be at risk for a heart attack, another stroke and, like many men his age, prostate problems. I should have asked about these at every visit and once a year done a rectal exam to assess prostate size and look for cancer. From reviewing the patient’s chart, it appeared I had limited my attention and my exam to his immediate problems — overlooking some of the other risks he faced.
I had asked him if he had problems urinating, and he had said no. I don’t think he was lying; I think he assumed that his bathroom difficulty was just one more skill stolen from him by his stroke. So much of the damage from that cerebral vascular accident was clearly visible and public. I suspect he felt that this disability, at least, could remain private.
And when he didn’t acknowledge any difficulties, I was happy to allow our visits to focus on getting his blood pressure and cholesterol under control, educating him on his medical problems, managing his meds and arranging his transportation and rehab. Everything else I treated as a long-term goal, to be attended to once these very pressing short-term needs were managed. Understandable perhaps, but it almost killed him. Practicing medicine is a balancing act — weighing immediate and long-term good. His case was a vivid reminder of what can happen when that balance is lost.
I didn’t visit my patient in the hospital. Normally I would have, but I was worried that he would be as angry with me as I was with myself. I saw him the following week. “I’m so sorry,” I started. He smiled his magnificent smile and squeezed my hand. “No matter,” he said, his words still slurred but back to their normal rhythm. He reached into his pocket, produced a few of his pecans from North Carolina and offered them to me. I took them gratefully. Perhaps I could be forgiven.