Monday, April 10, 2017

Second Opinions

Does this tell us anything about the state of medical care in America? I suspect it does. Since I am unfamiliar with these issues, I will let the Mayo Clinic report on its research.

You would think that diagnosing an illness falls within the purview of medical science. After all, we are not talking about psychological problems. As it turns out, however, medical science is not quite as scientific as we would like.

You know that people love to refer to experts and especially to experts with scientific expertise. They tell us that the science is settled and that we must do what the scientists tell us to do. Now, it turns out that when patients with serious illnesses seek a second opinion, the vast majority receive a new or a refined diagnosis.

The numbers are breathtaking. From Studyfind:

When it comes to treating a serious illness, two brains are better than one. A new study finds that nearly 9 in 10 people who go for a second opinion after seeing a doctor are likely to leave with a refined or new diagnosis from what they were first told. 

Researchers at the Mayo Clinic examined 286 patient records of individuals who had decided to consult a second opinion, hoping to determine whether being referred to a second specialist impacted one’s likelihood of receiving an accurate diagnosis.

The study, conducted using records of patients referred to the Mayo Clinic’s General Internal Medicine Division over a two-year period, ultimately found that when consulting a second opinion, the physician only confirmed the original diagnosis 12 percent of the time.

Less than 20% of the patients received the same diagnosis. The breakdown of the rest is revealing:

Among those with updated diagnoses, 66% received a refined or redefined diagnosis, while 21% were diagnosed with something completely different than what their first physician concluded.

Wherein lies the fault? The Mayo Clinic suggests that many primary care physicians are overly confident in their judgment. One suspects that an overly confident physician inspires more confidence in his patients, thus that the attitude is good for business, if bad for the patient's health:

Combine this with the fact that primary care physicians are often overly-confident in their diagnoses, not to mention how a high number of patients feel amiss about questioning their diagnoses, a massive issue is revealed.

Wherein lies the problem? Without having anything but anecdotal evidence, I suspect that the quality of American health care has declined. I do not think that the profession attracts the same caliber of candidates as it used to. And I also suspect that, as some physicians have told me, Medicare reimbursement rates, coupled with record-keeping requirements and malpractice insurance costs, are driving doctors out of business and are preventing good people from entering the business.

As for a statistic, one that I have not verified, a dozen or so years ago a cardiac surgeon, a man who could no longer make a living doing the surgery because Medicare reimbursement did not cover his ancillary costs and who complained bitterly over the fact that Medicare would no longer pay for two surgeons to perform heart surgery—it preferred one surgeon and one RN—told me that when he entered his residency program in the 1970s, there were nationally over 600 applicants for 120 residencies in cardio-thoracic surgery. Thus, there was a lot of competition. At the time we were talking, he said, there are 60 applicants for the same 120 places. At the least, we can conclude that the profession is less competitive and is no longer attracting the best and the brightest medical students. At some point or another this is going to show up in substandard medical care.

We read in the papers about the wonders of Medicare, and how much people like their Medicare. Some people want the entire health care system to resemble Medicare. The truth is, if you overregulate, overlitigate and underpay the practice of medicine the quality of health care is going to decline… because the quality of the people involved will decline.


trigger warning said...

One omission in this study is a breakdown of revised diagnosis by disease or disease type. I suspect expert disagreement is more frequent for complaints like chronic fatigue syndrome than, say, fractured tibias. The aggregate data are interesting, but not much more than that.

Medicine most certainly does not "attract", if that's the appropriate word, the same caliber of students. Medical schools annually report the demographic breakdown of admittees by race and MCAT/GPA. The data are shocking. Affirmative action has dumbed down the med school population.

Stuart Schneiderman said...

I agree that we ought to have known about disease types. I suspect that when they talk about "serious" illnesses they are not talking about broken bones or other fairly common problems.

JP said...

"One omission in this study is a breakdown of revised diagnosis by disease or disease type. I suspect expert disagreement is more frequent for complaints like chronic fatigue syndrome than, say, fractured tibias. The aggregate data are interesting, but not much more than that."

I have to deal with physician diagnosis and medical records on a daily basis.

I'm going to agree with trigger warning here. Broken tibias are obvious because they show up on basis x-rays. Chronic fatigue syndrome is basically a diagnosis of exclusion.

Plus, GP's refer to specialists, who then refine the diagnosis and perform additional tests, which potentially alter the diagnosis.

I also assume, although I could be wrong, that we are also talking about psychological/psychiatric diagnoses here, which, as Stuart would agree, is subject to fads and group-think.