About missing brain tumors & EBM:

summary:

1. Why it takes more time to study medicine than to study law
2. It takes a good doctor to make a mistake,
3. Ockham's razzor.


1.  Apart from neglect and bad work - to be judged properly by the 
institutions available - , missing serious health problems is part of 
the job. My rule is that every doctor makes one deadly mistake in his 
carreer and we better prepare students to that.  In medicine we 
estimated the pros & cons of the entire 2x2 table, including the harm 
to patients of the false-negatives and the consequences of the 
false-positives. Professionals in the legal bussiness look at the 
lower row of the 2x2 table only. That is why it takes more years to 
study medicine than to study law. 
2.   A second point is that EBM may solve many diagnostic problems, 
but not the problems after you made a mistake. This part of patient 
care - that is what it is - requires good quality of the 
doctor-patient communication during the diagnostic process, good 
registration and after the mistake was discovered again good 
comunication skills and guts. Halve of the law suit cases I have seen 
as an expert about allegations of GP's actually are not about EBM, 
but about communication after the mistake is discovered. Even deadly 
mistakes, if incidental, can be survived by physician and family if 
one says sorry, explains the process thoroughly etc. Hiding for the 
anger of patient & family, defensive remarks, rationalising events 
etc. certainly leads to problems. After all, the process has all the 
aspects of a posttraumatic stress disorder and of mourning. Handling 
a mistake requires the best you have as a doctor. 
A pecular paradox: 
You better be a very good doctor when making a serious mistake.... 
3.    The third point is more philosophical: Ockhams razzor or the 
Law of Parsimony. This logical law from around 1150 (actually from 
his teacher Dunn) states that it is better to look for one diagnosis 
that describes it all, than to look for more diagnoses. Many times 
this is the wrong rule of thumb. Many complaints appear to be caused 
by more than one pathophysiological process. 
In the case of headaches and brain tumors: the prevalence of 
tensiontype headache is about 70%, that of migraine is about 10%. By 
the laws of chance the detection of a brain tumor is more often 
preceded by years of headache than not.

sorry for the length of this mail,

Nico van Duijn, GP
Academic Medical Centre
University of Amsterdam

> Date:          Thu, 14 Jan 1999 14:50:40 -0500
> Subject:       Re: TV news and EBM
> From:          [log in to unmask] (Susan Kaiser, M.D.)
> To:            [log in to unmask]
> Reply-to:      [log in to unmask] (Susan Kaiser, M.D.)

> Dear Amit,
> 
> Of course we fear missing an important treatable diagnosis, when the
> consequences can be so devastating to our patients.  However, doesn't a
> great deal of this revolve around attitude?  .........

 There is a difference between making a mistake and negligence.

> American patients have the expectation that their doctors will be able to
> make every diagnosis and to restore them to good health..........
  
>.  We do not adequately discourage them from these beliefs in our 
omnipotence. ..................

> In choosing tests as well as therapies, EBM helps.  And so do good
> documentation and attentive two-way communication with the patient.
 
> Regards,
> Sue Kaiser
> 
> ==============================================
> >I sawa a young woman on TV news yesterday. She was in a wheel chair
> >sitting in a
> >court room before several serious looking jury and a judge along with TV new
> >crew and with near tears she said" For 4 years I told my doctor about my
> >headache and he did nothing - now they have detected a brain tumor." Everybody
> >seem to agree that the diagnostic test should have been done long ago and the
> >doctor didnot know his job.
> >The law is being changed in Minnesota as a result of this trial and they say
> >that now a patient can sue a doctor as late as 2 years after the diagnosis is
> >made, as opposed to the previous law - which stated that a doctor can not be
> >sued after 2 yrs of patient's last visit.
> >Apparantly this law is in effect in 47 other states in the US.
> >I find news like these making my life so much more difficult in teaching
> >medical
> >students about the choice of optimal diagnostic test and often unnecessary
> >tests
> >., ie CT scan to evaluate for headache.I am afraid that people will see this
> >case , avoid good history taking and physical exam or might just get that test
> >for  " I document that there is no tumor in this case- I dont care if there is
> >an microscopic one, I could always say that there was no macroscopic tumor!!"
> >I hope TV news does not impair our ability to practise EBM. How would the EBM
> >pundits tackle this situation or answer these kind of questions.
> >
> >Amit Ghosh, MD
> >General Internal Medicine
> >University of Minnesota
> >Minneapolis, MN 55455
> 
> ------------------------------------------------------------------------------
> Susan Kaiser, MD, PhD, FACS               Academic Phone: 212-241-3738
> Department of Surgery, Box 1259       Practice Phone: 212-241-3336
> The Mount Sinai School of Medicine   Fax: 212-534-2654
> One Gustave L. Levy Place                    Email: [log in to unmask]
> New York, NY 10029-6574                                [log in to unmask]
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> 
> 
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