diagnostic challenges

When you go to see the doctor because you are sick, the first order of business is to get a diagnosis. How does the doctor arrive at that? What does she need to know? And is there any way you can help your doctors with diagnostic challenges?

Meeting Diagnostic Challenges:

Getting the right diagnosis is crucial to getting the proper treatment. For many conditions, the diagnosis is pretty straightforward. But sometimes it can be quite complicated. The doctor may need to figure out which of many different diseases is causing the problems. When symptoms are not very specific, pinning down the diagnosis is a challenge. But diagnosis can also be difficult if the symptom is very specific but unfamiliar, like a black thumb on a gardener.

Diagnostic Challenges of Psychiatric or Physiological Causes:

It can be tricky to distinguish between a physiological condition that causes psychiatric symptoms and a psychiatric disorder that causes real physical symptoms. Find out how to get a truly independent second opinion, and why you should keep your primary care provider in the loop. When is it helpful to search the internet, and when might that be useless?

Here are some lists from our book, Top Screwups Doctors Make and How to Avoid Them.

Top Ten Reasons for Diagnostic Errors:

  • Overconfidence
  • Information overload
  • Going it alone
  • Tunnel vision
  • Time pressure
  • Missing test results
  • Ignoring drug side effects
  • Follow-up failure
  • Hurried hand-offs
  • Communication breakdown

Top 10 Questions to Ask to Reduce Diagnostic Disasters:

  • What are my primary concerns and symptoms?
  • How confident are you about this diagnosis?
  • What further tests might be helpful?
  • Will the test you are proposing change the treatment plan?
  • Are there any findings or symptoms that don't fit your diagnosis or that contradict it?
  • What else could it be?
  • Can you facilitate a second opinion?
  • When should I expect to see my test results? How will they be delivered?
  • What resources do you recommend for me to learn more about my diagnosis?
  • May I contact you by email/phone/text if my symptoms change or if I have an important question? If so, what is the contact info?

This Week’s Guest:

Lisa Sanders, MD,  is a clinician educator in the Primary Care Internal Medicine Residency Program at Yale School of Medicine. In addition to her work as a physician and teacher, she writes the popular Diagnosis column for the New York Times Magazine. Her column was the inspiration for the Fox program “House MD” (2004-2012) and she served as a technical adviser to the show.

Her books include Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis.

Listen to the Podcast:

The podcast of this program will be available the Monday after the broadcast date. The show can be streamed online from this site and podcasts can be downloaded for free. CDs may be purchased at any time after broadcast for $9.99.

Buy the CD

Download the mp3

Air Date:February 10, 2018

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  1. Pearl

    Medicine does not feel very “healing.” Seems to be about pharmaceuticals and stressful tests. NO doctor has ever asked me what I eat. I rarely am touched. There is never a follow-up call. I’ve been prescribed antibiotics (fluoroquinolones) which has horrid side effects … So I do my own research, use high quality food and various herbs.. try to avoid being in medical settings which I presume are crawling with germs!
    ALL THAT SAID, this “attitude” of mine may well keep me away from care when I need it. What a mess.

  2. Joni
    Branson, Missouri

    I’ve been an avid listener to People’s Pharmacy for years. So spot on!! I can sympathize with the above. I’m 78 and work every day. Have an Autoimmune issue plus Sjogrens Syndrome,plus high blood pressure on occasion. I hate drugs and refuse to take them. Big vitamin fan.NOW I have neuropathy!! Feet are frozen BUT numb. How can that be? I blame it on Cipro and Levaquin Barnes Hospital prescribed for repeated bouts of pneumonia. No more pneumonia but quality of life is extremely compromised. Sleep deprived for sure. Have to have heating pad on feet which shuts off automatically and I’m awake NOW. My PA wants to figure out what’s going on – took 9 vials of blood. Haven’t heard results yet. She referred me to Mayo but they said no – I wasn’t ill enough. Go figure. I want to work till I’m 80 but am going down hill. Hoping for an accurate diagnosis soon.

    • Patricia
      Delavan, WI

      Joni, What did you want the hospital to do when you had repeated bouts of pneumonia? Medicate you or let you fight the pneumonia on your own. You might not have been here to write about it.

  3. Allen
    Southeastern US

    Dear Joe and Terry,

    I am a family physician (30+ years; PGY 31 and counting). I see patients and teach medical students and residents at a large state medical school. I love your show and listen every chance I get. I read Dr. Sanders’ book (“Every Patient Tells a Story”) several years ago. It’s one of several books I frequently recommend to my students and residents (the other is “How Doctors Think” by Dr. Jerome Groopman).

    I misdiagnosed myself in medical school (long story!), but also was misdiagnosed a few years ago when hospitalized after a bad fall off a ladder, with a complicated pelvic fracture. I had a post-operative pulmonary embolism. I KNEW I was having a PE within 60 seconds. The orthopedic resident thought I was having a panic attack. Thankfully, his wise attending physician who had done my surgery the day before, listened to me and ordered an urgent chest CT, which confirmed the diagnosis of two emboli to my right lung.

    The inexperienced resident made a couple of bad assumptions and mistakes: 1) I was the physician who “knew too much” 2) a floor nurse told him I was “just anxious and probably having a panic attack” 3) The resident relied on the fact that they had taken careful preventive measures to lower my risk for a DVT (blood clot) – which was true. He was, however, overconfident in this and mistook risk REDUCTION for 100% risk PREVENTION. 4) He never examined me or touched me! 5) He was exhausted – despite the so-called 80 hour work rules for residents, I know he had been up all the night before operating, and the day before that assisting in my 6+ hour surgical procedure, and taking care of many other patients besides.

    The senior physician had seen this before and immediately knew what to do. I am grateful for his intervention and overruling the resident!

    Lots of lessons from my experience which I sometimes share with my learners; and a valuable reminder to me as I work with patients.

    Again, I love your show, learn a lot from it and gets lots of great ideas which I put to work in my practice. Thanks, God bless and keep up the great work!

  4. Sharon

    I TOTALLY agree with the two comments above. Doctors do not really listen to patients anymore. They think EVERY ONE needs expensive and mostly useless lab testing. When a patient describes their problem and symptoms, listening could provide MANY CLUES to what is going on. And most of the time, you get about 2-4 MINUTES to explain your problem, ask questions and then you are sent out the door with lab slip in hand, to undergo expensive testing that often does not provide answers to the problem. The American medical scene is very broken and not really about the patient anymore….only about money for the medical establishment.

  5. Bob
    South Carolina

    The goal of today’s doctors is to find a pill that will relieve the patient’s symptoms. They aren’t interested (or capable of) in solving the actual problem.

    • Marcia B

      Bob Of South Carolina: you got it 100%. They say “No cure, here’s a band aid..er I mean Rx pill. No cure.” No getting to the root of problem. You are correct. So many are just not interested. That is why so many of us have to research the internet and end up diagnosing ourselves. Pretty darn sad.

  6. Betty Rogers

    Okay. Now how does a patient deal with these situations?

  7. Betty R

    Okay. Now how does a patient deal with these situations?

  8. Pete Melrose
    South Carolina


    To providers and their patients,

    I agree with the “Top Ten Reasons for Diagnostic Errors” listed by Lisa Sanders, M.D., with whom I previously have communicated via email about this matter. Arguably, at least eight of the ten reasons are manifestations of cognitive overload, which I posit as the root cause of diagnostic errors specifically and medical mistakes in general; which now are the third leading cause of patient deaths after cancer and heart disease according to the article published by Marty Makary, M.D. of Johns Hopkins Medicine in 2017 (re http://www.bmj.com/content/353/bmj.i2139).

    If cognitive overload is the cause of diagnostic errors and other medical mistakes, that clearly cognitive support is required to mitigate those mistakes; and the real-time cognitive support required can be enabled only by state-of-the-art information technology systems of engagement (which leverage the last generation IT systems of record typified by electronic health record a.k.a. “EHR” systems such as Epic, Cerner and Meditech). The Cloud Healthcare Appliance Real-Time Solution as a Service (CHARTSaaS©) reference architecture is designed for healthcare provider subject matter experts to design, develop, deploy, operate and optimize clinical cognitive support IT applications a.k.a. “apps” without IT professional help and with minimal cost and complexity.

    Please review and comment on one of my blog posts at https://chartsaas.com or the white paper at http://bit.ly/2t79TCJ or my YouTube channel, CHARTSaaS, at http://bit.ly/2sVajvS, or the 12-minute presentation on automating the Hand-off Communications use case at https://mix.office.com/watch/4oo2wklb3302 or the more extensive 35-minute CHARTSaaS presentation at https://www.youtube.com/watch?v=7NWcok1fi8Q. I would be happy to discuss the matter of medical mistakes and the CHARTSaaS solution on a near-future edition of the People’s Pharmacy with Terry and Joe Gradon and/or any other appropriate forum. Please contact me at jpetermelrose@gmail.com or +1 (612)201-2301 to discuss and decide ln next steps to benefit healthcare providers and their patients — all of us.

    Thanks again, good wishes for another great day, and
    Best regards,
    Pete Melrose

    • Terry Graedon

      Pete, the “Top Ten Reasons” are ours, not Dr. Sanders. We don’t want her to have to take the blame for any mistakes we have made.
      Terry & Joe

  9. MarciaB

    Yes it is complicated but if dr. were more open minded it might not be. I have SO many symptoms of hypothyroidism its not funny. M.D. could not find anything. Went to endocrinologist and she ran blood tests out my a–. NOTHING. Everything was normal. Adrenals, kidneys, you name it NORMAL. What explains freezing cold, weight gain I cannot get rid of at 1200 calories, hair loss-goodby to vanity, foggy brain, spike in cholesterol when I do not eat meat–never had it before. I could go on but because those blood tests said NORMAL they were like, “be on your way”.

    Next stop is a doc I found whose web site says, “Where Eastern meets Western Medicine”. Hopefully he will help me. I walk 5 miles a day and started taking some iodine. The only thing I am surprised at is none of these doctors have checked hormone levels. Maybe at 60 they figure I have none. I don’t know how it all works. But enough of these book trained docs that if its not in the book we can’t help you. Thats what I PAID them for…to help. Medical training needs to step it up a bit.

  10. Cara

    Doctors don’t listen to their clients. They need to listen.
    You list questions to ask your doctor. They don’t want you to ask questions. They have no time for their clients. If they would listen and allow you to ask questions it would be a huge help in getting to the right diagnosis.

    • SJ

      High cholesterol isn’t solely from eating meat or butter. When you eat too many carbs that are starchy – like bread, pasta and white rice, they can cause high LDL. If you are skeptical, just give up eating carbs for a month and have your cholesterol checked again.

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