Finding Your Yellow Brick Road

I ask the question, should I have to pay to have my sprinklers moved on to my lawn, where they should have been placed originally.

A reader responded by asking if I thought a patient should have to pay for an error. Great question.

Well, that depends on how you define an error. As you know the Medicare National Bank has declared that they will stop paying for never events. These are events such as getting assaulted in the hospital, leaving an instrument in a surgical abdomen. Now, the MNB is trying to pawn off complications of illness like falling or stool infections or delirium as somehow a fault of the hard working doctors and nurses caring for very sick old people. Granted, steps can be taken to minimize the risk, such as hand washing, hiring perverts to stand in the crapper while granny does her thing or sedating the hell out of pappy with haldol and ativan. But to declare these never events as errors or events that shouldn't be paid "extra" for is placing blame on the health care workers instead of mother nature.

Sick people get sicker. Sick people have complications of illness. Should a hospital be paid extra for a patient that develops aspiration pneumonia as a result of delirium and spends 2 weeks in the intensive care unit? Absolutely they should. Should a hospital be paid for the total colectomy from life threatening pseudomembranous colitis as a result of clostridium difficile over growth from antibiotic use? Absolutely. These are complications of illness, not errors. Not never events.

Should a patient pay for services that results in the misdiagnosis of an illness? Absolutely. Patients don't come to a doctor with the complaint "I have heart failure". They come to a doctor with the complaints "I am coughing. I am short of breath." Part of being a doctor is figuring out the mystery. There is not a single pathway to diagnosis. Which is why quality indicators don't do jack for the evaluation of illness. Every human is different. The history can be full of clues as to the correct diagnosis. As can the exam. But all disease has a spectrum. You can have pneumonia, or heart failure or COPD and they can all present exactly the same. You can have one, two or all three of these conditions simultaneously and it can present exactly the same. You can have none of these and think you have all three. There is no Star Ship Enterprise magic wand that spits out your diagnosis on day one. It is a process. An evaluation of trends. And evaluation of change through time.

Often, heart failure patients are misdiagnosed as pneumonia. Often pneumonia patients are misdiagnosed as heart failure. The list goes on and on and on. Disease is not black and white. You can have mild, moderate and severe forms. You can have multiple simultaneous conditions that all look the same. The clues are often buried in the history. The testing often can sway a diagnosis one way or another. Is the white count high? Is the BNP (a heart failure marker) elevated? Are there changes of COPD on CXR? Is there wheezing? Do they have orthopnea? PND?

Misdiagnosis is part of the process of developing the differential diagnosis Trial and error is part of the healing process and the evaluation and even the treatment. Everybody responds differently to the same treatments. We see that in blood pressure, diabetes, heart failure, coronary disease, arrhythmias and all other chronic medical illness where no single treatment plan is appropriate for everyone. When patients fail to improve with the treatment plan, a reevaluation is in order. But failure to make the diagnosis on the first day, or the first visit or even the first week or even the first month is not malpractice (although many lawyers want you to believe it is). It is not negligence. It is not bad care. It is normal care. It is the process of elimination. It is the process of evaluation. It is the process of treatment.

I can't tell you how many times a patient gets admitted with one diagnosis that is not confirmed after further evaluation. Daily. Multiple times a day. That's medicine for you. Some want to believe this is bad care. Those people are idiots. Doctors are constantly re-evaluating the situation. Making decisions hundreds of times a day based on subjective and objective data. Knowing what to pursue and what to ignore. It is not as simple as the sprinklers being placed on your neighbors yard. That is the equivalent of leaving surgical equipment in your belly after surgery. A misdiagnosis is not an error. It is part of the normal evaluation of illness. So many people don't understand that. To reach the yellow brick road, you must first travel down the bumpy cobble stone path for many, many miles. In the case of chronic unexplained illness, that bumpy road may never end.