Before surviving a heart attack, I was what you might consider a model patient. I was always cooperative, deferential and polite with few if any health issues to worry my doctors. Physicians have the letters M.D. after their names, and know all about medicine. I had no reason to ever doubt them.
But all that pretty much changed forever after I was misdiagnosed with indigestion in the middle of a heart attack – despite presenting with textbook symptoms like chest pain, nausea, sweating and pain radiating down my left arm.
The E.R. doc who completely missed my heart attack was a pleasant enough middle-aged man who told me in his confident doctorly tone that not only did I NOT have heart problems, but he could tell just by looking at me that I was clearly in the “right demographic” for having acid reflux. But before he sent me home from hospital that day (feeling truly embarrassed for having made a fuss over nothing!), one of his E.R. nurses had already cautioned me: “He is a very good doctor” and “He does not like to be questioned!” – this stern warning after I’d had the temerity to actually ask him out loud:
“But Doctor, what about this pain radiating down my left arm?”
Turns out that being misdiagnosed and sent home in mid-heart attack is, tragically, not uncommon for women. According to research* reported in the New England Journal of Medicine, in fact, women under the age of 55 are seven times more likely to be misdiagnosed during a cardiac event compared to our male counterparts.
And when the American Heart Association surveyed physicians in 2005 to find out how many of them were aware of the fact that more women than men die of cardiovascular disease every year, only 8% of family physicians knew it.
Even more appalling, only 17% of cardiologists were aware of this. (Cardiologists! This is their business. This is all they do!)
As cardiologist Dr. Tracy Stevens of Kansas City points out:
“Physicians are still practicing medicine based on cardiac studies performed mostly on white, middle-aged men.”
Dr. Stevens’ observation got me thinking about what other facts our docs may not be aware of, and about how that ignorance has to be affecting the way they practice medicine. After all, the British Medical Journal once estimated that doctors have to carry an astonishing two million facts in their heads to help them diagnose illness and keep track of treatment options.
Who can keep two million facts straight? Never mind updated . .
Sometimes what your doctor doesn’t know can have painful ramifications. We know, for example, that up to 40% of medical malpractice lawsuits are for something called “failure to diagnose”.
Dr. Janice Barnhardt‘s 2004 research reported to the Society of General Internal Medicine in Chicago that year found almost one third of internists and half of the OB/GYNs studied did not know that tobacco use is the leading cause of heart attack in young women. For their young female patients who did smoke, only two thirds of internists and barely half of OB/GYNs actively counselled these patients to quit smoking.
And consider the simple x-ray. The explosion of revolutionary medical imaging technology has swept through all fields of medicine. One in five North Americans will receive a CT scan during any given year, but emerging research suggests that at least one-third of those scans are unnecessary.
Is it possible that some doctors are uninformed about when to order CT scans appropriately?
Dr. Rebecca Smith-Bindman is a noted expert in the risks of radiographs on patients. She warns:
“A 20-year old woman who gets an abdominal-pelvic CT scan (i.e., just about any young woman coming to the E.R. with belly pain) has a 1 in 250 chance of getting cancer from that single scan. Researchers now estimate that 15,000 people will die from the direct effects of the 72 million CT scans performed in 2007 alone.”
She also found that some hospital CT scanners deliver radiation doses 66% higher than the usually-quoted doses, and that there are staggering variations (up to 13-fold) among different scanners performing precisely the same test.
Another of her warnings:
“Witness the billboards for $1,000 total body scans that line Florida’s highways – scans that, when performed in healthy people searching for asymptomatic tumors, undoubtedly will cause more cancers than they cure.”
But here’s the truly frightening news about Dr. Smith-Bindman’s warnings. A 2004 study found that fewer than 50% of radiologists and barely 9% of E.R. docs were aware of the possibility that CT scans could increase the subsequent risk of cancer.
Another headline-grabbing development in radiography is CT colonography which, according to many physicians, now replaces the “old” optical colonoscopy.
But here’s what researchers had to say about CT colonography in the American Journal of Gastroenterology:
“CT colonography is an effective screening test for colorectal neoplasia. However, it is more expensive and generally less effective than optical colonoscopy.” (Am J Gastroenterol. 2007 February; 102(2): 380–390)
More expensive? Less effective?!
Consider also a recent New York Times article featuring harshly critical observations from experts like Dr. Christopher DiGiovanni, a professor of orthopedics and a sports medicine specialist at Brown University. He and some of his fellow orthopods are taking a stand against what they see as the vast overuse of magnetic resonance imaging (MRI) diagnostic technology in their own medical specialty. Dr. DiGiovanni explained:
“It is very rare for an MRI to come back with the words ‘normal study’. I can’t tell you the last time I’ve seen that. In sports medicine, where injuries are typically torn muscles or tendons or narrow cracks in bones, MRIs often are not needed. We usually can figure out what is wrong with just a careful medical history, a physical exam and, sometimes, a simple X-ray.”
Indeed, the sensitivity of an MRI in diagnosing an anterior cruciate ligament tear in the knee is about 90%. But as orthopedic surgeon Dr. Jonathan Cluett points out, the sensitivity of finding an ACL tear on physical examination by an experienced orthopod is also about 90%.
And when sports medicine orthopedist Dr. James Andrews studied the MRIs of 31 perfectly healthy professional baseball pitchers, these MRIs found abnormal shoulder cartilage in 90% of them and abnormal rotator cuff tendons in 87%. He warned:
“If you want an excuse to operate on a pitcher’s throwing shoulder, just get an MRI.”
A study published in the journal Birth suggests that younger obstetricians are more likely to recommend a Caesarian-section delivery than a natural birth, despite a number of recent studies showing C-sections pose health risks for both mothers and babies. A 2009 New England Journal of Medicine study, for example, says repeat C-sections can double the risk of complications for newborns, including neonatal death.
A 2005 McGill University study published in the scholarly journal, Sexually Transmitted Diseases, revealed that many of Canada’s doctors were significantly uninformed about the transmission rates for two serious sexually transmitted infections. When asked to state the probability of HIV transmission during one unprotected sexual encounter, only 1.4% of them knew that the probability was below 0.5%. Barely 5% of these respondents knew that the rate of transmission for chlamydia was between 30-40%.
But wait. There’s more.
Find out why gynecologists continue to recommend hormone therapy despite significant evidence of cardiac complications reported by the massive Women’s Health Initiative study. Or how stent-happy cardiologists are implanting coronary stents that may not be necessary at all. Or ponder why your doctor keeps prescribing inappropriate antibiotics for your strep throat when there is no scientific evidence that antibiotics will help your throat get any better any faster compared to doing nothing.
* Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342:1163-1170.
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The Ethical Nag 
I’m not at all surprised by this list of things many doctors may not be aware of. How could they? None of us has an encyclopedic knowledge of ANY given subject (that’s what Google’s for) but the difference is that patients face life and death consequences if doctors don’t actually know what we trust doctors to know about.
It’s true, Tzatziki – my mechanic hasn’t yet been able to figure out why my car horn honks when I shift down, but that lack of knowledge isn’t going to kill me.
It is not humanly possible to know everything from all angles. This is why it is so important for people to be informed about health and be aware of their own bodies. In my experience the people who end up knowing the most about a disease (eg asthma, diabetes) are those who have lived with it for years.
You are so right – patients need to be both informed and accountable. But just yesterday, a middle-aged woman in my heart health talk audience put her hand up and said: “I’ve been taking pills for a ‘heart rhythm problem’ – what does that mean?”
Yikes.
In an ideal world much of the role of a doctor should be to educate people about health so that situations like that one do not arise. Alas we have a long way to go
Agreed. It’s also a generational problem – many patients are used to just sitting there quietly while their doctor interprets test results, reviews treatment plans, prescribes meds. When you ask them later: “What did the doctor tell you?”, they can be quite confused, even though at the time, they may have been smiling and nodding as if they understood the doc completely.
Well, there’s certainly room to forgive doctors for not knowing everything. However, I have encountered such an amazing array of incompetent doctors of late that it has truly shaken me.
I’m an RN and while I keep my eyes open, I think I’m more than fair – forgiving, even, to a point. Nevertheless, based on my experiences, I believe we have a serious problem. It’s not just an educate the patient problem, though that’s certainly sorely needed, and it’s not just an “I can’t possibly know everything” problem, though that’s certainly true, as well.
It’s a problem with incompetence! Now I am basing this on my own personal experiences, so I will acknowledge this “error in assumption” right now. You are right that anecdotes and personal experiences are no basis for making generalized assumptions. However, were you me, you might have a hard time remembering that. If I weren’t a nurse and weren’t paying attention, I’d have been in surgery at least 3 times in the last few years when there was absolutely no need for any of them. All were errors in diagnosis. Along with the unneeded surgeries, I’d also have permanent damage from an injury, had I not hesitated before doing the exercises prescribed by the specialist I saw. Thankfully, I did hesitate and got a second opinion. The exercises would have been perfect, except for the small problem that he had completely misdiagnosed the nature of my injury. This kind of repeated experience is very scary. And to make it worse, these doctors were all subspecialists!
In one case, I’m convinced it was a case of needing to make money, with that doctor recommending unneeded surgery and fast. However, the primary problem seems to be poor assessment skills. Here is one striking example. While it didn’t cause me any harm, it certainly got my attention and I’ll wager it will get yours:
I was in the hospital to determine if I had had a heart attack. The ER doctor had listened to my heart and had heard a heart murmur. “Did you know you have a murmur?” he asked me. I told him “No.” He reassured me that it wasn’t a murmur to worry about, so I was glad to hear that. Once in the hospital, I mentioned this murmur to the first of many cardiologists who saw me. After he completed his exam, I remembered what the ER doctor had said and remarked, “You know, the ER doctor said I have a murmur.” He said, “You do?” He bent to listen again, stood up after a bit and said, “Yes, you do have a murmur.” I was surprised by this and I repeated the sequence with the next cardiologist who saw me. Same response. “You do?” He listens again. “Oh, yes. You do.” I repeated this with every cardiologist I saw, and I had a slew of them as “cardiac hospitalists.”
I got exactly the same response from every one. Not a single exception. I was not at risk of harm by this failure on their part, but thank heaven for that! Not a single heart specialist seeing me for a heart problem had assessed my heart sounds well enough to hear the heart murmur. This and my other unsettling experiences have nothing to do with “not being able to remember it all.” They are examples – far too many examples to be encountered by a single patient – of plain old incompetence. And I repeat: These are ALL SUB-SPECIALISTS!
I want to know: what is going on?
Hi Bev – that is quite the story, and the fact that the murmur was missed repeatedly (by cardiologists!) is especially troubling. Interesting that the ER doc picked it up, but not the people whose sole focus is the heart.
From Medscape Medical News & Oncology
J Natl Cancer Inst. Published online November 9, 2011
US Colorectal Cancer Screening Strategy Questioned
Nick Mulcahy, November 9, 2011 — The use of colonoscopy as the primary screening strategy for colorectal cancer in the United States, which has been famously dubbed “going the distance,” might be a case of going too far, suggests an editorial published online November 9 in the Journal of the National Cancer Institute.
[…]
The United States “adopted a primary colonoscopy strategy for [colorectal cancer] screening” despite a lack of strong evidence that its benefits surpass those of other strategies”, they say.
[…]
The “great majority” of findings at colonoscopy are not cancers, but instead are small low-risk adenomas and nonadenomatous polyps, they emphasize. Current practice in the United States dictates that all polyps, regardless of size, be removed. This practice, which has “an uncertain net effect” on the patient, has led gastroenterologists astray, they note. “When our goal changes from reducing [colorectal cancer] mortality within reasonable levels of harms and costs to eradicating every existing polyp, we are taking our eyes off the ball,” they write.
[…]
Read the entire Medscape article
But there are many trails of corn to follow!
I’m going down the rabbit-hole of following the links—- again. I hope others can persevere.
Thanks for those links, cave.
On Being A ‘Difficult’ Patient
Found at:
http://content.healthaffairs.org/content/27/5/1416.full
“In the clinical world, the term difficult is applied to a variety of patients: the noncompliant; the rude, abusive, and manipulative; the malingering; the mentally ill; the skeptical.
In my case, I too frequently challenged my doctors with questions and too often chose a treatment that differed from what they’d recommended. I consider myself to be an assertive patient, but it was clear on many occasions that some providers thought I deserved the “difficult” label.”
” Being difficult was my natural response when my doctor was incompetent, rude, or domineering. I didn’t need a physician to be my “perfect agent” (the phrase from health economics that the physician is the patient’s agent).
I needed a physician to be an additional source of information and insight to support my informed decision making. I wasn’t interested in being told what to do, and I expected my doctors to respect my right to make truly informed choices that were consistent with the way in which I wanted to intervene in my disease and live my life.”