Posts Tagged differential diagnosis
On 7/23/13 Laura Landro of the Wall Street Journal published an article about “A Better Digital Diagnosis”. The essence of the story is on-line symptom checkers are available and may be useful to patients. Just input your symptoms, get your diagnosis, call for an appointment, and get your treatment. Sounds good; possibly too good.
Below are listed some good sources for information, some symptom checkers and some software to download to a smart phone. The software is actually intended for health care providers and may have too much jargon for the average person.
However, before you jump in to get a diagnosis for what ails you try a test run. OK, this is not a double blind experiment but worth your time. The idea is to look up the details of a known disease then enter the published symptoms in the symptom checker and see what comes out. You will find a huge variation, often the expected diagnosis does not even show up at all!
For example: plantar faciitis. This is a common disease of the foot caused by inflammation of the connective tissue in the sole of the foot especially causing pain just in front of the heel bone. The striking and often diagnostic symptom is heel pain on first getting out of bed and walking. The pain gets better after a few minutes of walking. It is common in runners and people who spend lots of time standing. Being overweight or wearing hard-sole shoes contributes. As people get older the natural padding of the sole thins which is probably why the problem is common after age 50.
The symptoms were entered into several of the symptom checkers. Esagil seemed to give every diagnosis know to medical science and nothing would narrow down the possibilities — every symptom could be due to syphilis. The Mayo Clinic site required some human thinking. Foot pain showed several areas to read about: after reading the material the diagnosis of plantar faciitis seems to fit.
The diagnosis of plantar faciitis can usually be made by a primary care provider in a flash — it is a common problem. Worrying about whether you have syphilis is a waste of time and a real source of anxiety — if you ask the primary care provider whether you could have syphilis, you can almost count on some testing.
Once you have tested any symptom-checker and understand the limitations they can be helpful. It’s almost like a second opinion about a problem. Discuss the findings with the health care provider early in an office visit — don’t spring the information after the provider makes a plan. Be a team player to prevent being at odds with the provider.
Good sources for medical information:
Evaluate symptoms / differential diagnosis
Smart Phone Apps
- Differential Daignosis by mHealth Labs, LLC
- Differential Diagmosis by Borm Bruckmeier Publishing LLC
- Your Rapid Diagnosis for Android by WWW Machealth
- Differential Diagnosis from the BMJ Group
- Your Rapid Diagnosis by WWW Machealth
- VisualDx by Logical Images
- Common Symptom Guide by Mobile Systems:
Making a diagnosis is difficult. And, doctors sometimes get it wrong. “Wrong” is often harmless, usually expensive, and sometimes deadly.
An article about incorrect diagnosis appeared this month in the British Medical Journal Quality and Safety which has been widely reported, including by the Wall Street Journal. Dr. Tehrani and his co-authors correlated health insurance claims (diagnosis) with malpractice suits. They found “diagnostic errors appear to be the most common, most costly and most dangerous of medical mistakes.”
One might think the errors happen because the underlying problem is very rare. On the contrary, the bulk of errors happen with common conditions.
Another article this month in JAMA Internal Medicine by Dr. Singh and co-workers reported on common types of diagnostic errors — many of which were common in primary care: (italics are blog examples)
- no chest x-ray for cough and high fever
- no chest x-ray for cough and high fever
- Decompensated congestive heart failure
- no BNpeptide checked
- Acute renal failure
- no check of basic metabolic panel for fatigue
- ignoring Mammogram findings or blood in sputum
- Urinary tract infections
- not checking urinalysis or treating soon enough
The flaw in the process that contributed to the wrong diagnosis included:
- Inadequate patient encounter (too short or not focused on problem)
- Not seeking referral when needed (like not getting a cardiology consult for chest pain)
- Patient related factors (not returning for follow-up)
- Not taking risk factors into account (like family history of colon cancer)
- Losing track of test results (urinalysis report filed but not viewed)
- Not getting the right test (not getting a chest x-ray for shortness of breath)
Problems at the time of patient encounter are a major contributor:
- Poor history taking (provider did not listen or ask questions)
- Inadequate examination (provider did not examine problem area — like a breast nodule)
- Inadequate testing (not considering a colonoscopy for blood in the stool)
When a person has a health problem the whole idea is to connect the dots …problem…diagnosis…treatment. If the diagnosis is not correct then good treatment is disconnected.
Providers often do not consider enough possible causes for abnormal findings. Those possibilities are called the “differential diagnosis”. There are books and several free sites on the Internet that provide such lists. One such site is DiagnosisPro. If you like other sites leave a comment please. Some electronic record applications include a differential diagnosis automatically — nice feature which should always be installed.
So, what is the solution? Most experts agree, the quality of the provider-patient interaction must improve. Providers need to follow known guidelines plus use differential diagnosis aids. Patients need to look out for themselves by using the Internet or books to understand symptoms and test results. The best solution is a stronger partnership between patients and providers. See earlier posts in this blog about shared decision-making and patient centered care.
Can all errors be prevented? NO. To err is human. The point is to minimize the errors, and there is obviously a lot of room for improvement.