by Carolyn Thomas ♥ @HeartSisters
Australian researcher Dr. Mary Dahm and I were emailing back and forth about her recently published study on diagnostic uncertainty in medicine (one of my favourite subjects, I might add – especially when it involves female heart patients). I mentioned to her that the Emergency physician who had misdiagnosed my heart attack as acid reflux seemed remarkably confident at the time – despite being remarkably wrong. That misplaced confidence is what researchers who study diagnostic error call unwarranted certainty – a contributing risk factor for misdiagnosis. But Dr. Dahm raised the issue of whether diagnosing is what Emergency physicians actually do:
“The question about whether or not Emergency Department doctors diagnose is highly contested within the specialty. Regardless, they do exclude life-and limb-threatening conditions.” .
? “Whether or not Emergency Department doctors diagnose!?”
? “Highly contested within the specialty!?”
In my own arguably limited experience of explaining symptoms to Emergency physicians for the express purpose of coming up with an accurate diagnosis, I’d always assumed that these doctors certainly do diagnose. Happily, the first Emergency doc I’d ever met years before my heart attack correctly identified broken bones right off the bat following my rush hour bicycle accident. And aren’t Emergency docs in reality the diagnostic gatekeepers for all heart patients in trouble?
In fact, nobody waiting in Emergency with cardiac symptoms gets sent up to the hospital’s cardiology wing until an Emergency physician first identifies their condition as heart-related. That’s why I was sent home in mid-heart attack: the Emergency doc declared that I was “in the right demographic for acid reflux.'”
Isn’t that diagnosing? And isn’t being able to “exclude life-and-limb-threatening conditions” a diagnostic tool as well?
Deciding what the problem is NOT can indeed help physicians rule out the possible diagnoses that aren’t the ones causing symptoms at the time – but only if what’s being excluded deserves to be excluded. And that requires some level of diagnostic certainty.
In my case, that first supremely confident Emergency doc who misdiagnosed me had already mistakenly excluded heart disease (my actual diagnosis) – despite my textbook cardiac symptoms of central chest pain, nausea, sweating and pain down my left arm.
Oregon Emergency physician Dr. Edward Lew once described his job as “frequently misunderstood”:
“I am an emergency medicine physician. I save lives.
“Acute-care scenarios are why we exist — or why we train. That’s our expertise. Clearly, it would be disingenuous to proclaim we are masters of every organ in the body. Rather, Emergency medicine physicians are masters of resuscitating the dying, the dead — and stabilizing the sick.”
Dr. Kathleen Clem is an Emergency physician in New Hampshire. She explained the most challenging aspects of her own career in Emergency medicine in this essay:
“People think the most challenging part of being an Emergency physician is the traumas and all of the really sick patients. For me, that’s not it. I love challenging cases. I’m trained for that, and know how to take care of really sick patients.
“The hardest thing for me is patients with unrealistic expectations. In certain instances, patients think that ‘No matter what’s wrong with me, I’m going to the Emergency Department and that doctor should figure it out and provide a cure.’
“But those kinds of things are difficult. It’s also difficult when a patient comes in with the expectation they will be admitted to the hospital and it turns out that it’s safe for them to have their work-ups done as an outpatient. They can be very disappointed and feel that the Emergency physician should have the power to admit them. Patients have to meet pre-specified indications to be admitted to the hospital. It’s really not up to Emergency physicians to determine if someone will be admitted.”
So if it’s not up to Emergency physicians to determine which patient will or will not be admitted to the hospital, who does make that determination?
The Emerg doc who decided I had acid reflux did not make eye contact with me, did not introduce himself, did not call in a cardiologist, and spent significantly less than one minute in my little curtained cubicle before sending me home with instructions to ask my family physician for an antacid drug prescription.
To my knowledge, he made that call on the spot, at about the same time he was telling me:
“Your cardiac enzyme blood test came back normal. We’ll do another blood test – but it will be normal, too.” *
I suspect that this doctor was basing his call on what Dr. Jerome Goopman’s book “How Doctors Think“ calls diagnosis momentum, one of “a cascade of cognitive errors” that can result in misdiagnosis. Groopman explains that specialists seem particularly susceptible to this cognitive error:
“Once an authoritative senior physician has fixed a label to the medical problem, it usually stays firmly attached – because the specialist is usually right.”
Rod Brouhard, the former chair of the Emergency Medical Services Advisory Council in San Francisco, wrote a Very Well Health column called “Important Information You Should Know About the Emergency Department”:
“The Emergency Department might not be exactly what you thought it was. You don’t go to an Emergency doc hoping they’ll diagnose multiple sclerosis or cancer. They sometimes will identify a problem and send you to a specialist – the expert who may then order further tests, diagnose the condition and create a treatment plan. Most importantly, Emergency docs do spot-check medicine. They take snapshots of a person’s medical history and make quick decisions about what to do.”
Dr. Anton Helman is an Emergency physician at North York General and an Assistant Professor at the University of Toronto Division of Emergency Medicine. He’s also the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Institute, and the founder, podcast host and chief editor of Emergency Medicine Cases.
Podcast #62 is called Diagnostic Decision-Making in Emergency Medicine, which made me feel hopeful that their team might shed some light on diagnosis as something that Emergency docs do or do not do. This podcast is aimed at healthcare professionals but still useful for those of us who have not been to med school – if you’re a bit of a diagnostic nerd like me.
Dr. Helman starts by asking himself the question: “Are we good diagnosticians?” He says that he was “stunned” to find out from a systematic review of autopsy studies conducted over four decades that one in 10 patients had experienced a major pre-death diagnostic error – despite significant advances in diagnostic imaging and testing over those years. His second question to himself: “What’s causing this poor diagnostic performance?”
Dr. Walter Himmel, in the same podcast, added:
“There is no absolute truth in medicine. Our job as diagnosticians is to estimate the truth.”
He then listed the four principles of diagnostic decision analysis in Emergency Departments (adapted from the landmark 1985 paper ‘Pathways Through Uncertainty’) and published in the Canadian Medical Association Journal. These are:
- Patients do not have disease, only a probability of disease.
- Diagnostic tests are merely revisions of probabilities.
- Test interpretation should precede test ordering.
- If the revisions in probabilities caused by a diagnostic test do not entail a change in subsequent management, use of the test should be reconsidered.
Do those four principles sound like Emergency docs don’t actually diagnose?
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* P.S. FUN FACT (for those readers wondering why abnormal cardiac enzyme blood test results may look “normal” if you’re a woman) as explained by Vancouver researcher Dr. Karin Humphries: (2)
“The presence of the cardiac enzyme called troponin is typically a standard marker for heart muscle damage caused almost always by a heart attack. But the commonly used blood test for troponin threshold in this test is based on a level that’s considered appropriate for men, but may be set too high for women – whose blood tests would be interpreted as ‘normal’. Setting a lower female-specific troponin threshold would improve the diagnosis, treatment and outcomes of women presenting to the Emergency Department.”
.
1. Helman, A, Himmel, W, Hicks, C, Dushenski, D. “Decision-Making in Emergency Medicine – Cognitive Debiasing, Situational Awareness & Preferred Error.” Emergency Medicine Cases. January, 2016.
2. Zhao Y, Humphries KH et al. “High-Sensitivity Cardiac Troponin – Optimizing the Diagnosis of Acute Myocardial Infarction/Injury in Women (CODE-MI).” Am Heart J. 2020 Nov;229:18-28.
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Q: In your own experience, do Emergency Physicians diagnose?
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NOTE FROM CAROLYN: I wrote more about cardiac diagnosis and misdiagnosis in my book “A Woman’s Guide to Living with Heart Disease“. You can ask for it at bookstores (please support your local independent bookseller!) or order it online (paperback, hardcover or e-book) at Amazon – or order it directly from my publisher Johns Hopkins University Press (use their code HTWN to save 30% off the list price).
Crystal ball image: Pixabay
SEE ALSO:
- More articles about diagnosis and misdiagnosis in women’s cardiac care
Heart Sisters 
Hello Carolyn,
I had my stress test done in our local hospital. When I did not do well, I needed to be transferred. The Doctor that was in with the stress test contacted everyone at the other hospital. Even though I had to wait for 3 hours in the ambulance till a bed was ready in the ER. Once I was moved from ambulance to hallway, I only saw heart doctors. But when I came home and had to go back twice for extreme pain under my ribs and could not breathe, I was sent home with Motrin (which is not really that good for a heart patient) and instructions to see my family doctor. I am so thankful that my family doctor is the way she is – always wants to get to the bottom of things.
I can also say that we got the same treatment from the pet ER just a couple weeks ago. Give her this and follow up with your vet.
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Hello Susan – “Take this, follow up with somebody else!” sounds familiar! That response mimics the quotes in this post from Emergency physicians who say this is what they’re trained to do: “spot-check medicine” and quick decisions on what to do next.
The doctor who did your stress test did a good job communicating your transfer details (which seems to me to be a basic courtesy that any healthcare professional should do when a patient needs to be moved to a bigger hospital for care). Waiting for three hours in the ambulance is tough – especially after you’d just had a test that didn’t go well. Very stressful – although waiting for a bed to become vacant is becoming unfortunately common with overcrowded Emergency departments these days. 😦
Hope you – and your pet! – are feeling better now. Take care. . . ♥
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Fantastic column. It makes me think about Kaiser, an HMO in some states and the HMO that US healthcare models & law is based upon.
For Kaiser, all expedited “emergencies” come in through the ER which have hours-long waits. I was with Kaiser at one point, and realized that the systematized and systemic bias (and a tendency for outdated orthodoxy (GI vs cardiac, too young, insufficiently elevated troponins) could be the death of me, though I eventually had all the tests via a young female internist.
I was threatened /scared with “you don’t want a cath, do you? You could die..), though the challenge cath at nearby Stanford, WAS the ticket to diagnosis), and learning that my symptoms were not that unusual.. for FEMALES.
I cannot stand that these same biases and errors continue onward. Thankfully, the collective voice of women, the MDs who have taken in unpopular research to believe us, and the visibility through our courage to not stand down through dismissal and shame, has yielded great progress. It must go faster.. much faster.
Now for the Emergency Physicians.. who have such great power to become knowledgeable or to perpetuate the errors of 1 in 10. We’re coming for you. . .
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Hello again Mary – lovely to hear from you on this important subject.
Using a trip to the cath lab as a threat meant to frighten a patient is appalling – as if that’s the last possible thing a heart patient could want! The last thing heart patients want is to be dismissed without an appropriate diagnosis and treatment plan! Especially in your case, when your Stanford experience resulted in an accurate diagnosis.
You raise such an interesting point, and one that I sometimes neglect to repeat: the transformative power of healthcare professionals whose professional focus is on making medicine better for all. There are MANY of them out there (often, but not always, women). I’m often amazed by the determined power of these people to, as you say, harness the “collective voice of women” to improve the status quo.
The gender gap in cardiology is not limited to heart patients – it is the history of society and of women’s health care in general (as illustrated in outstanding books like Maya Dusenbery’s “Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick.”
Hope you are doing well!
Take care, Mary. . . ♥
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This gets so complicated because now it takes so long to get into a primary care physician or to get a specialty referral that people go to the ER for care.
The ER docs can expedite a work-up so they are functioning as primary.
I went to the ER last summer when I couldn’t tolerate angina and persistent PVC’s but the wait time to see my cardiologist was months. The hospitalist that saw me got me into the cardiology clinic and cardiac rehab as part of his discharge orders!
Backward for sure.
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Sara, this seems to be the sad reality now. In my town alone, there are over 100,000 people without a family doctor – with NO sign of a big influx of new GPs arriving here any time soon to open their family practice clinics! I live in daily dread that my own wonderful family doc will one day take early retirement (she’s already had to cut back her practice by 800 patients and work part-time due to family health issues at home – I was one of the extremely lucky ones who wasn’t fired!)
Meanwhile, Urgent Care (walk-in) Clinics have block-long lineups starting early in the morning which means that all of each day’s available appointment spots are booked within minutes. So the Emergency Department is realistically often the only resource in sight for desperate and vulnerable people – thus the horror stories we hear of people spending DAYS waiting in Emerg.
Luckily, the hospitalist that saw you when you went to Emergency was on the ball (including a cardiac rehab referral!? Impressive!) But it’s unfortunate that you had to suffer intolerable angina and persistent PVCs until you were able to get care.
Somehow, this IS all backward indeed!
Take care, stay safe. . . . ♥
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This reminds me of an ER situation from about 10 years ago. I had just returned from India and was having cough and shortness of breath. My out-patient allergy/asthma doc listened to my lungs and ordered a chest x-ray and a D-Dimer blood test. I got a phone call as soon as the blood results came back, my D-Dimer was over 900 (normal D-Dimer range is 220 to 500). He told me to go directly to the ER as I might have a Pulmonary Embolism (PE).
When I got to the ER, I was not short of breath and had no signs of a deep vein thrombosis. The ER doc said “You do not have the symptom profile for a PE, that level DDimer could be caused by something else. I don’t feel that a CT scan for ruling out PE is warranted. But if you feel you want that test, I can order it, but I can’t guarantee your insurance will pay for it.” My jaw just dropped.
I did ask for the test, since that’s what my Asthma doc sent me there for, and it did turn out to be negative for PE. Good outcome but the process was frightening.
For this and many other reasons, we in America often feel like Insurance companies are running our health care.
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Hello Jill – sadly, your health care system IS being run by the U.S. insurance industry. 😦
I’ve heard of American doctors raging against the humiliating experience of being on the phone with insurance company “cubicle docs” – who have the ultimate power to second-guess, delay or flat out deny a patient’s in-person physician’s treatment recommendations.
Your trip to the ER 10 years ago does sound frightening! As you say: good outcome for you – so why do things feel so bad getting to that outcome? Acute pulmonary embolism is such an extremely serious diagnosis. And few things in medicine are more demoralizing, in my opinion, than having dueling doctors engaged in a public pissing contest over your care. What’s an average patient to do?!
I’m not a physician of course, but I’ve observed that some Emerg docs may consider the D-Dimer test less reliable because although it’s a test that looks for evidence of blood clots, it’s also a test that can look positive due to non-blood clot conditions (e.g. pregnancy, infection, rheumatoid arthritis, cancer, trauma, recent surgery, etc. etc.)
So glad you survived that experience with NO PE!
Take care, stay safe. . . ♥
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This is astonishing.
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I thought so too, Dr. Anne! ♥
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