I recently presented my diagnostic talk — Learning to Think Like a Clinician — at the Virginia ACP meeting. Afterwards several physicians wanted to discuss the reasons for diagnostic challenges. They convinced me that many regulations from CMS and other insurers have influenced policies that increase anchoring and diagnostic inertia.
When the emergency department physicians admit to the hospital, they have to give an admission diagnosis. At least in the United States, I believe they cannot admit for abnormal chest x-ray, or fever, but rather they must postulate a diagnosis. That diagnosis then drives case managers and protocols. Patients often receive their first treatments before the admitting physician has even met the patient.
The emergency physicians get criticized if they do not proceed in a timely fashion. The hospital worries that they have a diagnosis that supports admission rather than observation status. If they designate the wrong status, they face a financial problem.
But patients do not always arrive with diagnoses. Some diagnoses take time. Patients would benefit if the diagnosis was purposely made unknown disease with manifestations rather than pick a diagnosis for billing and quality purposes.
Too often, the physicians stated, a diagnosis induces a therapeutic freight train. And then if the patient is not discharged promptly (according to the expectations of the admission diagnosis) the admitting physician gets criticized.
Something is wrong with the system. (Actually much is wrong because we do not really have a system, rather we have rules.) We need ways to more acceptably label a patient as a diagnostic puzzle. We need the “system” to allow us to not know the diagnosis and realize that pursuing the diagnosis is job #1.
We must develop systems to avoid diagnostic anchoring and inertia. Our patients deserve our full diagnostic attention. Unfortunately, we see too many diagnostic misadventures.
Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.
