Every Patient Tells a Story

Lisa Sanders M.D.

Diagnosis:Mysterious Psychosis

• 70-90% of diagnoses are made based on the patient’s history alone.

Diagnostic Triad

Patient

Diagnosis Doctor

Story

Diagnostic Triad

Patient

Diagnosis DoctorStory

Diagnostic Triad

Patient

Diagnosis Doctor

Story

• 5 doctors in 5 different practices in urban and rural England

• 80 patients without a diagnosis

• Each doctor recorded their differential diagnosis after each step of the evaluation: history, physical, test results

Hampton, BMJ 1975

• Correct diagnosis made after:

• History 68% (66/80)

• Physical exam 9% (7/80)

• Testing 9% (7/80)

Hampton, BMJ 1975

• 4 physicians in practice is Utah

• 80 patients without a diagnosis

• Each doctor recorded their differential diagnosis after each step of the evaluation: history, physical, test results

Peterson BMJ 1992

• Correct diagnosis made after

• History 76% (61/80 )

• Physical exam 12% (10/80)

• Testing 11% (9/80)

Peterson BMJ 1992

• Patients spoke for an average of 23 seconds before the physician interrupted them with a question

• Some physicians waited only 3 seconds before interrupting the patient

• Doctors were more likely to interrupt if the patient was a woman than if it was a man

• Male doctors were more likely to interrupt than their female counterparts

• 2% of patients resume their story after being interrupted.

• When interviewed after a doctor patient encounter, doctors and patients did not agree on what the encounter was about

• Most patients had problems they didn’t get to address

• Time pressure

Why doctors miss the story:

• The average in-office doctor visit lasts 16-22 minutes

• Most stories last 60 seconds and none lasted longer than 150 seconds - 2.5 minutes

• Visits where doctors did not interrupt lasted on average 1 minute longer

Krista’s Story

Lemierre’s Syndrome

External Jugular vein

Why doctors miss the story:

• Lack of training

Why doctors miss the story:

• Discomfort with patient emotions

Dan’s Story

• 55% of patients surveyed said that their greatest concern after seeing a doctor was a misdiagnosis

• Up to 15% of diagnoses made in primary care specialties will be wrong

“An estimated 40,000-80,000 hospital deaths result from misdiagnoses

annually.”Newman-Toker, JAMA, 2009

• Ask your doctor: “What else could this be if it’s not that?”

• Tell your story - even after you’re interrupted

Diagnostic Triad

Patient

Diagnosis Doctor

Story

• Between 2-3% of patient leave the hospital AMA (Against Medical Advice)

• 25-50% of patients do not take their medications as prescribed

Andy’s Story

Andy: Linds, something's wrong

Lindsay: what do you mean?

Andy: my memory is all f'ed up

Lindsay: what is wrong?

Lindsay: call the DOCTOR NOW! tell them it is an emergency.

Lindsay: How is it all f'ed up?

Andy: short term, i can't remember anything

Limbic Encephalitis

Diagnostic Triad

Patient

Diagnosis Doctor

Story

Thank you