Misdiagnosis is Common
Despite the rapid technological advances made in modern medicine, we have entered an era where misdiagnosis is rampant. This is as true for medical illness as it is for psychiatric illnesses.
In most cases, these misdiagnosis cases are due to inadequate diagnostic testing to ensure that the underlying illness is correctly identified.
Millions of man hours of scientific research and development have resulted in some truly amazing tools to aid the physician in diagnosis and treatment. Advancements in electronics have made possible Computerized Tomography (CT) scanning, Magnetic Resonance Imaging (MRI), Ultrasound Imaging, Endoscopy, and countless other diagnostic tools.
Unfortunately, however, in many cases accessiblity to these diagnostic tools is restricted, either for economic or political reasons. In countries like Canada, where universal healthcare is rationed, waiting lists for CT scans or MRI's can be several months long. Additionally, physicians are often pressured by the medical insurer to restrict the number of diagnostic tests performed in an attempt to control costs.
There has also been a failure on the part of many physicians to adopt modern diagnostic technologies. Take one look at the average general practictioner's office and you'll see it looks much the way it did 100 years ago. The average physician still relies on their fallible personal experience, often unaware of their own biases and flawed beliefs. As older, more experienced physicians are replaced by younger, less experienced ones, this exacerbates the problem.
In most industries where troubleshooting and diagnostic testing is required to repair machinery or computerized equipment, technicians are equipped with advanced diagnostic software and testing equipment. In this way, the technician does not need to rely solely on their limited personal experience, but can draw on the experience of many technicians by employing the intelligence built into the software. It may be that some physicians feel threatened by such diagnostic software. It is sobering to realize that more medical knowledge can packed onto one CD ROM than any one doctor can accumulate in an entire career. It is unfortunate that many physicians resist these helpful tools, for in the hands of an experienced practitioner, these tools can be of tremendous utility. Certainly, the mechanic and the computer technician, who work on much simpler machines than the physician, rely on these tools extensively to correctly diagnose and repair malfunctioning machinery.
If diagnostic software were universally used by general practioners, it would undoubtedly specify several diagnostic tests if presenting symptoms included anorexia, vomiting, weight loss, constipation, or abdominal pain. Physicians, however, like most human beings are prone to jump to incorrect conclusions due to limited personal experience, ignorance, suggestability (see page on public awareness)or performance pressures.
When the medical insurer puts pressure on the physician to limit the number and type of diagnostic tests employed, it increases the risk of misdiagnosis, and also the potential for malpractice litigation. There are several strategies physicians can employ to mitigate these risks.
Never Challenge Another Physician's Diagnosis
Perhaps one of the most effective strategies to minimize the risk of malpractice litigation is to always have other physicians to back up your diagnosis and treatment protocols. For this to work there has to be an unwritten rule among physicians that no one will question the original diagnosis or make any effort to look for a differential diagnosis. To do so would invite reciprocal action, which in time, would be almost inevitable, and at the very least would strain working relationships between physicians. These strategic alliances among physicians can very effectively mitigate the risk of malpractice litigation. Unfortunately, they are definitely not in the best interest of the patient, as it is often necessary to find a whole new medical group or travel to another state or country to get un unbiased second opinion. This phenomenon became readily apparent in our daughter's case, as it was necessary to travel several thousand miles to find a physician who was not afraid to challenge the original diagnosis.
Practicing medicine is a risky business, and eventually everyone messes up. Malpractice suits can seriously impact a physician's livelihood and potentially jeopardize their career. For this reason, there is no incentive to admit mistakes, or to correct them. There is no mechanism in place to facilitate learning from others' mistakes, since the system effectively covers these up. Many jokes have been made about doctors burying their mistakes, and in many respects, this happens regularly when it comes to misdiagnosis.
The same phenomenon occurs in eating disorder programs, which generally make little or no effort to challenge the original diagnosis of anorexia nervosa or bulimia nervosa. If you ask any eating disorder progam director what tests they insist on before accepting patients into their program, they'll generally say that the patient already has been diagnosed, and their purpose is to treat the illness, and not to disprove the original diagnosis (see page on diagnostic tests done by eating disorder clinics). Certainly, for many private clinics that charge tens of thousands of dollars per week for treatment, it is not in their best interest to look for differential diagnoses. There is little risk of malpractice for these clinics, which can generally ensure the safety of the patient and achieve weight gain through force feeding and close supervision. If the patient commits suicide or dies of complications of malnutrition, it would be difficult to pinpoint blame in a malpractice suit. These clinics also often rely on the referrals of physicians, who may not appreciate having their diagnosis challenged.
In countries with universal medicare, such as Canada, healthcare is often rationed in an effort to control spiralling costs. Much like in the chicken or dairy industry, the Canadian federal government practices supply management with regards to medical services and health care practitioners. Governments try to predict how many doctors, nurses, technicians, etc. they'll need in the coming decades, and only open spaces in universities and colleges to meet the anticipated need. What they fail to realize, however, is that unlike the chicken or dairy farmer, the doctor, nurse, or technician is mobile, and can practice their craft anywhere, and quite often in another country.
Many Canadian doctors are lured to better paying jobs in the U.S. where they can actually have a say in how many hours they have to work or how much they can charge. In Canada, most doctors work on a fee-for-service basis, with the fee schedule set by an agreement between the government medical insurer and the provincial medical association. Unlike most states in the U.S., where antitrust legislation prevents one doctor from discussing their fee schedule with another (which could lead to price-fixing), Canadian doctors all are expected to charge the same for any particular service.
Like any business person, an American doctor (except those bound by HMO contracts) is free to charge what the market will bear. Therefore, if he finds himself too busy, he can simply raise his fees so he can work less hours for the same money. The law of supply and demand would effctively reduce his workload while maintaining his revenue. In Canada however, the physician is not free to charge what the market will bear. Therefore he can only generate more revenue by processing more patients. The net result of this situation is that it is to the physician's advantage to develop a backlog of patients. You''ll see countless examples of this in GPs' offices, where generally the patients are lined up in the waitng room, expected to wait up to an hour for a five minute appointment with the doctor. You'll also see it in long wait lists to see a specialist, a surgeon, or for diagnostic testing. Unfortunately, in many cases, the doctor who makes the most money is the one who can process the most patients. The system also creates a significant temptation to make fraudulent claims for services that were never rendered, since the patient never receives an invoice for services. Patient confidentiality and an almost non-existent auditing system make it unlikely for a physician to be caught.
Canadian physicians can also raise their incomes through job action, which is a regular occurence in provinces like B.C. When my wife needed her gallbladder removed, surgeons at our local hosptial were on strike, necessitating her transfer by ambulance to another city. While our daughter was suffering from her gallbladder disease one year later, the BCMA was again in the midst of job action. Most Americans would never stand for their doctor refusing to render services. They would simply find another doctor. Unfortunately, Canadians have no such luxury, since there are so few doctors per capita and they are so highly organized.
The various provincial medical associations also play a role in ensuring these long wait lists by limiting the number of physicians who can practice in any one area, since it ensures higher incomes for their members. The downside to this scenario however, is that due to the high demand placed on Canadian physicians, many are simply burning out, or moving to other countries.
Legally Defining Disease
Legal implications of diagnosis and treatment with respect to disease have forced medical practitioners to develop rigid definitions of diseases. This is especially true of mental illnesses.
Regarding anorexia nervosa and bulimia nervosa, there is constant debate and disagreement about just what the diagnostic criteria should be. Some camps want to eliminate weight preoccupation as one of the criteria. If this were to occur, we would see a quantum leap in males being diagnosed with the disease.
Common sense tells us that someone who is not purposely trying to lose weight likely has some biological disorder causing the weight loss. Yet often making a diagnosis regarding pshychiatric disorders has little to do with common sense and more to do with ensuring a "legally safe" diagnosis which meets all the diagnostic criteria, thus protecting the practitioner from possible future litigation.
If a physician or therapist can demonstrate that a patient meets the diagnostic criteria of AN, they generally will expose themselves to less litigation risk by sending the patient to an ED clinic, rather than pursuing a search for differential diagnoses. They are also less likely to be harassed by the medical insurer for ordering too many tests.
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