A Physician's Recommendations for Avoiding Misdiagnosing Patients

July 24, 2014

Every patient encounter carries with it the possibility of error. And every error can cause problems for the patient. So what do we do as physicians?

I can recall several patients who suffered because no one thought of the diagnosis. And so they were treated for the wrong diagnosis.

The first time I remember seeing this was in medical school. A patient described the onset of Jacksonian march seizures, sometimes losing consciousness due to secondary generalization. It was one of the clearest descriptions of Jacksonian march seizures I have ever heard from a patient.

But this patient had for years been labeled a schizophrenic because doctors and therapists only listened to the first part of her description of her “crazy spells.” These episodes had made her afraid to go out, since she never knew when they would occur. And her manner of speaking came across as odd, to say the least, to her middle class, West Coast providers. She reminded me of people I had met on a bus in Appalachia as a child. She had never completed grade school and spoke an unusual patois.

Despite undergoing years of incorrect and inappropriate treatment, this patient was more fortunate than another patient I can never forget. She was an 18-year-old honors student at a local college. Suddenly, she began to act strangely, and the police were called. Because her behavior was strange, she was taken to the local mental hospital and started on anti-psychotics. The nurses noted some high fevers and called the psychiatrist on call, who thought it was a drug reaction and treated the patient for that. But the patient didn’t get better. In fact, she died.

I met her on an autopsy slab. A beautiful young girl, whose life was cut short. When we opened her head, it was obvious. A thick coating of grayish yellow pus covered every surface of her brain. And, when we did the microscopic study, the pus was encasing perforating vessels, and there were numerous microinfarcts, throughout the brain and brainstem. She had died of meningitis.

A third patient had been a bank manager, when she started acting strangely. Her behavior became so extreme that she lost her job, and then her husband divorced her and her grown children became estranged. She deteriorated to the point that she was homeless. Finally she, too, was brought to a psych hospital. She too, was diagnosed as schizophrenic, even though the onset was in her 40s. But, on her second or third hospitalization, someone ordered a CT, and then an MRI and found a meningioma. I operated on it. The patient gradually improved. She got a job, though not at the level she was used to. She tried to make amends with her family. They had a hard time, because they remembered all she had put them through.

With my own illness, I first thought it was gallbladder, appropriate for my age and gender. But it wasn’t. Then, I had to go to the hospital due to the pain of a ruptured viscus. It seemed to be appendicitis, but wasn’t quite that simple. Finally, I was on my way to the necessary treatment four months after my first hospital visit, but nearly eight months after my first symptoms. Would it have made a difference? Will it make a difference? I don’t know, but hope for the best.

Another mistaken diagnosis that I personally experienced occurred during my stay in the recovery room. Despite having an epidural placed, I was in severe pain. I asked the nurse for more for pain. She told me that I shouldn’t be having any pain since I had an epidural. I suggested that she ask the doctors for more medication. After all, I’d just had a major surgery. I suggested some medications that I would give patients in similar situations.

Finally the doctor came over, a resident who had rotated through the hospital where I worked. The nurse told him that I had been asking for pain medication since I woke up, and even asking for drugs by name. He responded that, of course, I knew what drugs to use since I was an attending surgeon at a neighboring hospital. The nurse, who clearly had not read my record, turned 50 shades of red. It was clear that she had been convinced that I was a drug abuser.

Every patient encounter carries with it the possibility of error. And every error can cause problems for the patient. So what do we do as physicians?

We must remember our duty to do the best for the patient. And that means we must try to be our best. We must try to be informed, not just in a narrow part of our own specialty, but in neighboring ones. And, we must look harder when things don’t fit. We can’t try to force the patient to fit in the box of our preferred, or most common, or most lucrative diagnosis. If the patient doesn’t fit, there’s probably a reason.