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Medical errors caused by doctors not examining their patients

Medical errors caused by doctors not examining their patients

800px-Child_examined_by_doctorStories of shocking medical errors that occur because doctors miss something during a physical exam — or forget to examine a patient at all — are common. Every physician knows them, says Stanford physician Abraham Verghese.

A missed breast mass in a patient that presents with chest pain. A missed gunshot wound in a patient wheeled into the emergency room. A missed pregnancy in a patient with a large belly.

But little has been done to quantify this type of medical error. In a first step toward creating data-based measurements of medical errors due to inadequacies in the physical exam, a study published recently in the American Journal of Medicine reports on a collection of 208 such occurrences, and their consequences.

I think of it as my worst nightmare, that a patient will slip through my grasp with a diagnosable or treatable condition.

Researchers collected the incidents from responses to surveys sent to 5,000 physicians asking for first-hand stories of such medical errors. The cause of the oversights in the 208 responses was most often a failure to perform the physical examination at all — in 63 percent of the cases, the study states. Other times, errors were caused by misinterpretating or overlooking physical signs.

“I think of it as my worst nightmare, that a patient will slip through my grasp with a diagnosable or treatable condition,” says Verghese, who is known as a champion of bedside medicine. “I call it the ‘low hanging fruit,'” he says, referring to the simple yet essential process of conducting the physical exam — and its low cost.

The consequences of these mostly preventable mistakes varied from missed or delayed diagnoses in 65 percent of the patients, to incorrect diagnosis in 27 percent or unnecessary treatment in 18 percent, the study says.

“We are talking about missing things that are very common, a mass, or a sore or a heart murmur or something in the lungs, that leads you down the wrong path,” says John Ioannidis, MD, senior author of the study. “This is something that happens everyday, and it’s something that could be corrected to a good extent.”

A well-known report conducted by the Institute of Medicine titled, “To Err is Human,” found that medical errors cause nearly 100,000 deaths per year, according to the study. The extent to which physical examination errors contribute to this figure remains uncertain and, as a result, little has been done to prevent them, it says.

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Education, Stanford Medicine Unplugged

My struggles with the third-year of med school – and the words that helped me

My struggles with the third-year of med school - and the words that helped me

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

495524570_415c91b283_z“I remember how hard it was to be a third-year medical student,” one of my residents once said to me. “You have to appear constantly enthusiastic. You feel continuously judged and evaluated. And worst of all, you know, deep inside, that if you were to get a cold or something and not show up one day, not one bit of the daily workflow would change because as far as pivotal people on the team go, you aren’t one of them.”

And with those words, my resident smiled and let me go home early, while she and the other residents stayed to finish up last-minute tasks and sign out to the night team. I was too excited about getting out early to think much about what she said that day (golden rule of third year: if your resident sends you home early, don’t argue. Count your blessings, and go home). But more and more, her words have begun to resonate with me – they summarize so well what I’ve struggled with as a third-year med student.

On a day-to-day basis, third year is awesome. The patients I’ve met have been absolutely incredible, and I’ve been so grateful for the stories they share and their willingness to teach me about their medical conditions. When I first started third year, spending time with patients was more than fulfilling for me, and I felt lucky that, as the medical student on the team, I had more time than others to do that. But, after a couple months on the wards, I felt myself growing a little restless – I wanted to do more to contribute to patient care in a meaningful way.

The trouble is that, as a student, it’s often difficult to do more. For instance, on some rotations, my classmates and I were told that we didn’t need to write notes, because they couldn’t be used as official patient notes anyway. At first, I rejoiced – writing notes, while at first novel and exciting, quickly becomes a tedious chore. But then, I realized that not writing a note meant one less way I could contribute to the team. On other rotations, even when we did write notes, the Epic medical student note template would have red, bolded text at the top that said something like, “Medical student notes are for educational purposes only. No part of this note may be copied or used.” That made me feel even less worthwhile – why was I spending time writing this note if it was very obviously not usable?

Ironically, this lack of a defined medical student role is also one of the greatest blessings of third year because it relieves you of responsibility. There were many days on my medicine rotation where our team was swamped with admissions, but since I was already carrying three or four patients of my own, my team would let me go home early, while they stayed to work till late hours, often past midnight.

But that doesn’t make it easier to come to terms with the fact that as a medical student, finding meaningful ways to contribute to the team is sometimes challenging.

I mentioned my unease to one of my faculty mentors, who gave me a piece of advice I’ve tried hard to incorporate into third year: “Your job as a medical student is to make yourself two things: teachable and indispensable. Be an excited learner, call consults, follow up on studies for patients, offer to update discharge summaries, give presentations and teach the team. Make it so that if you’re not there, the team feels the weight of your absence.”

Of course, what my mentor told me is easier said than done. But it’s helped me increase my sense of self-worth as the medical student on the team – and if any of you readers are or will soon be third/fourth year medical students, maybe it’ll help you as well. No doubt, something else that’ll help me feel better is a little vacation to reset after six straight months of clerkships – so it’s off to winter break for me! Happy Holidays and early Happy New Year to all of you!

Hamsika Chandrasekar is a third-year student at Stanford’s medical school. She has an interest in medical education and pediatrics. 

Photo by Adrian Clark

Education, Patient Care, Stanford Medicine Unplugged

Harm versus pain, an important distinction for physicians

Harm versus pain, an important distinction for physicians

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

13866052723_2020820f89_zAbove all, we medical students are told to do no harm. It’s a maxim that we follow religiously and is one of the pillars guiding the ethics of practicing medicine. But our professors don’t tell us what really constitutes harm because it’s not so easy to define.

The first time we touched a patient during a physical exam, we were timid with our hands and instruments, hyperaware of any twitches or jerks that could indicate pain. We made sure to attend to all the patient’s discomforts. Before we entered the room, we adjusted the collars of white coats to appear pleasing. We warmed our hands and dabbed the sweat off our palms. When we palpated his abdomen, we pressed ever so gently, barely making a crater in his stomach. Even when placing our stethoscopes on his chest, we would do so delicately because if we pressed too hard, it would leave a bruise — or so we feared. Reflexes often could not be evoked because we didn’t want to fracture his kneecap by tapping it too hard with our hammers.

When we practice medicine, we walk a tight rope between life and death that has no safety net.

It is easy to conflate the two, but pain is not synonymous with harm. And we must realize that important distinction to practice good medicine. After all, in order to prevent, treat, or even cure disease, we will invariably have to cause the patient some degree of pain, and the physical exam is no exception. We must press the abdomen with enough force to feel the edges of internal organs or shine a blinding light into the pupils. But these tasks cause only relative discomfort.

What about more invasive procedures?

Mammograms can be painful and emotionally draining. Colonoscopies are uncomfortable and awkward. Prostate exams and pap smears force the patient into an undignified and vulnerable position. Even the quickest blood draw can tap into incapacitating needle phobias. And chemotherapy, the epitome of doing good by causing suffering, intends to trade months of agony for potentially years of survival.

So do we give a free pass to those patients who don’t want to undergo these procedures and whom we don’t want to see suffer? The greatest fear of any practitioner is to accidentally hurt the patient, and naturally, we are tempted to the easy route of inaction to avoid this possibility. Ironically, this deep-seated fear that can make us competent and caring physicians can also inhibit us from doing our duty.

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Education, Nutrition, Public Health, Research, Stanford News, Videos

Online Stanford nutrition course improves participants’ eating habits, study finds

Online Stanford nutrition course improves participants' eating habits, study finds

I’m a big fan of Stanford’s free online course on child nutrition and cooking. And it’s not just me: Since the course launched in early 2014, more than 200,000 people have enrolled and watched the quick, informative, charming videos about understanding nutrition and making healthy food for kids. My favorite video, above, shows how to cook toad-in-a-hole, a comfort food I’ve loved since my own childhood.

Recently, instructor Maya Adam, MD, and her colleagues tested the effect of completing the course. When they designed the course, they hoped it would improve participants’ eating habits. A few other institutions had seen promising results from smaller online nutrition courses, but none of those combined nutrition instruction with hands-on demos of how to actually put their advice into practice in the kitchen. Yet other research suggests that making this connection between the “why” and “how” of healthy eating is important, since many people say that their lack of cooking know-how keeps them from eating well.

The results of the study, which appears in the International Journal of Behavioral Nutrition and Physical Activity, showed that the course is a success. Based on data from 7,422 participants surveyed about their eating habits before and after taking the course, the material presented helped participants cook fresh foods at home more often and eat more fresh fruits and vegetables. After the course, participants were also more likely to say that their previous day’s dinner was enjoyable and healthy.

“This is part of a growing body of research suggesting that just learning to cook can lead to improved dietary intake, which has amazing implications for public health interventions aimed at preventing overweight and obesity,” Adam told me in an e-mail.

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Cardiovascular Medicine, Education, Patient Care, Stanford Medicine Unplugged

Pathology vs. patients: Balancing morbid fascination with heart-felt care

Pathology vs. patients: Balancing morbid fascination with heart-felt care

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category.

3690107655_eef7c24702_zI recently saw a patient who, against all odds, survived an aortic dissection. Miraculously, he was alive after the wall of his aorta — the largest and most important vessel in the body — began to rip apart. Aortic dissections are so violent and agonizing that a large portion of these patients don’t survive. Yet somehow, my patient was still able to sit upright in his chair and recount his story to me just a day after his surgery, a testimony to how far medicine has advanced and to how lucky he was.

I admit that I was more fascinated by his cardiovascular travails than I was concerned by his suffering and the long road of recovery awaiting him. After all, it was only a few months prior that we learned the pathophysiology of aortic dissections. And now in front of me was a real life case study accompanied by authentic lab values, imaging, and physical exam findings, all of which were free for me to probe.

Had I encountered him prior to medical school, I would have spent more time to express words of support and sympathy — he’s a survivor and he needed any and all means of encouragement to return to some semblance of normalcy.

Once we have reached the end of the journey, the patient himself is buried underneath our medical knowledge and the disease has seized all our attention.

But medical school, for better or worse, changes your perception of patients and their plights. Despite all the efforts in the curriculum to teach us to view the patient as a whole, the endless nights and sacrificed weekends of burying ourselves in textbooks and scrambled jargon eventually dehumanizes patients and forces the spotlight on the pathology.

Call it insensitivity or callousness, but this morbid fascination with human illness is one of the paradoxes in medicine — that we must sympathize with the patient as well as with the disease that is harming him and may eventually kill him.

And for better or worse, becoming a competent doctor requires some modicum of this perverse curiosity, a veritable double-edged sword. Anyone who lacks it would simply not be able to survive four years of college dedicated mostly to studying basic biology, another four years of medical school to studying clinical presentations, and then finally another handful of years to specialize, all the while taking on hundreds of thousands of dollars in debt and sacrificing young adulthood. Yet, insidiously, once we have reached the end of the journey, the patient himself is buried underneath our medical knowledge and the disease has seized all our attention.

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Education, Events, Stanford News

TEDMED, in pictures

TEDMED, in pictures

A group of MD and PhD students represented Stanford at TEDMED 2015, which was held last week. Several students have written about their experiences on Scope, and here now are some of their photos from the two-and-a-half-day event.

More photos of Stanford Medicine events, people and places can be found on Instagram.

Photos by Eric Trac, Afaaf Shakir, Chao Long, Lichy Han and Thomas Chew

Education, Sports

How to combine anesthesiology, internal medicine and rock climbing

How to combine anesthesiology, internal medicine and rock climbing

Michael Lin, M.D. at the Stanford Hospital and Clinics on Wednesday, September 23, 2015.

I’ll admit it: I’m in awe of, and a little intimidated by, medical residents. Between the early call times, long hours, and flurry of patients and cases, I often find myself wondering how these doctors-in-training manage to do it all.

So I was amazed to learn about Michael Lin, a fourth-year resident in Stanford’s combined internal medicine-anesthesia residency program. While most residents focus on just one field – like dermatology or surgery — Lin spends his time training in both anesthesia and internal medicine. He’s equally at home in the operating room prepping patients for surgery and in the internal medicine clinic treating outpatients.

But Lin also manages to squeeze in rock climbing outings to the gym and to meccas such as Yosemite National Park.

During a recent interview, I had the chance to speak with Lin about his dual interests, his experience at Stanford, and why doctors make great rock climbing partners. Here’s an excerpt from our Q&A:

What initially drew you to both fields?

When I was a medical student, I was interested in critical care and I was trying to decide which training route I wanted to take during my residency. I met with a lot of anesthesiologists and pulmonary critical care doctors who said that you get certain, specific skill sets from the medicine training and the anesthesia training. I realized that I didn’t want to choose. I wanted both skill sets.

One thing that has really drawn residents into this program is the critical care component. The ICU is really the intersection of medicine and anesthesia. You’re encountering critically ill patients with severe pathologies, so you need skills in acute resuscitation and advanced medical support that anesthesiologists are accustomed to providing in the OR, but you also need to treat the underlying pathology that landed them there in the first place, which is more aligned with the work of internal medicine physicians.

And as for why doctors make the best rock climbers? Lin has a simple response: “They’re detailed oriented and stay calm under stress, and you can trust them with your life.”

The only downside, he says, is that they always seem to be on call.

Previously: Stanford Internal Medicine Residency program to host Google+ Hangout, My couple’s match: Applying for medical residency as a duo and “We are a team”: Advice for new residents from chief residents, in their own words
Photo by Norbert von der Groeben

Education, Pediatrics, Stanford Medicine Unplugged

Empathy and the darker side of pediatrics

Empathy and the darker side of pediatrics

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category.

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I’m currently just over halfway through my pediatrics rotation, having recently finished up four weeks on inpatient peds and just started my month of outpatient peds.

Before this rotation, when I thought about pediatric medicine, I thought about diagnoses like asthma, croup, foreign body ingestions, and rashes. I never really thought about child abuse, or – as the medical terminology goes – “non-accidental trauma.” And yet, I saw all too much of it this past month on the wards.

Our 6 a.m. sign out one morning went something like, “Patient X, here for NAT, steadily improving, currently in CPS (Child Protective Services) custody, awaiting foster family placement.” When we met this young patient later that same morning, I found a strong mix of emotions stirring inside me: first disbelief, then overwhelming sadness, then – rapidly – anger.

How could ANY parent do this to their baby? This question repeated itself in my mind, over and over and over. I literally could not wrap my head around it. Here is this beautiful, helpless little human being – what could possibly make someone do harm to this child?

I was distressed and distracted throughout rounds that morning, until finally – unable to stay quiet – I confided my thoughts to one of the other members on the medical team, who said: “I know it feels hard to understand. But, take just a moment, and think about it from the parents’ perspective: They are no longer allowed to visit their own child. And they have to explain to literally everyone they know – friends, family, colleagues, other children in the home – why they no longer have their baby.”

Her words stunned me into momentary silence. Never had I thought to empathize with the parents of our NAT patient.

Somehow, I had taken that 2-minute sound bite uttered during morning sign-out and transformed it into a mental battlefield, with the health-care team on one side, fighting valiantly to protect this child, and the parents on the other, a medical story of “good” vs. “evil.” But my fellow team member was right: This situation was awful all around. These parents no longer had a child, the child no longer had parents, and sometimes – if the patient had siblings – the siblings too were taken into CPS custody.

This experience taught me how absolutely vital it is to find ways to empathize with every patient and every family, no matter what the circumstances. 

I feel like this is particularly relevant in the inpatient setting, where we see patients for days – which sometimes become weeks and months – at a time. We connect with our patients: They’re often the first people we see when we get into the hospital and the last ones we see when we leave. We feel like we know all about them, about their families, about their values. But we don’t.

We’re witnessing this small window of their lives that has brought them to the hospital. And as easy as it is sometimes to ask question and judge – particularly in the setting of something as sensitive as child abuse – it’s not our place to do so.

Hamsika Chandrasekar is a third-year student at Stanford’s medical school. She has an interest in medical education and pediatrics. 

Photo by 3rdparty

Education, Stanford News, Videos

“Dear Future Doctor, here’s a few things you’ll need to know”: Med students release parody video

"Dear Future Doctor, here's a few things you'll need to know": Med students release parody video

Ready for the first-ever musical parody produced by Stanford medical students? Filmed on campus last month and released this afternoon, Dear Future Doctor features a group of mostly first-years singing and dancing to the tune of one of Meghan Trainor’s recent hits. Featuring characters like the Late Doctor, the Greedy Doctor and the Celebrity Doctor, the song also – in the words of producer/writer/editor/first-year student Gun Ho Lee – aims to teach a lesson “on what the future doctor is NOT to do.”

The song “is meant to be a satire of the 21st century American medical system,” director/writer/ second-year student Joshua Wortzel elaborates. “In her song, Meghan Trainor pokes fun at some of the unfortunate aspects of modern courtship and gender norms” – and Dear Future Doctor, in turn, pokes fun at some of the things that “we medical students learn about becoming doctors.”

Enjoy!

Education, Events, Science

To boost diversity in academia, “true grit” is needed

To boost diversity in academia, "true grit" is needed

photo (1)With evangelical fervor, Freeman Hrabowski, PhD, president of the University of Maryland-Baltimore County (UMBC), challenged the School of Medicine to tackle inequality throughout its ranks, an effort that — if successful — could spill out to benefit society at large.

“It takes effort, being proactive, not being defensive, and being honest and transparent,” Hrabowski told a packed crowd here yesterday. His talk was the part of the Dean’s Lecture Series, which is focused on diversity.

A mathematician, Hrabowski is a national leader in the field of science education and is author of the recently published book, Holding Fast to Dreams: Empowering youth from the Civil Rights crusade to STEM achievement. He was incarcerated during a Civil Rights march in the 1960s and currently campaigns for inclusiveness at all levels of academia.

Dean Lloyd Minor, MD, lauded Hrabowski: “Personally, I have found Freeman to be an enormous source of inspiration, advice and of wisdom in my leadership career. He is an exceedingly wise leader, who measures his leadership by the lives that he impacts.”

Confronting entrenched notions about race and gender and STEM fields (science, technology, engineering and math) won’t be easy, Hrabowski admitted. He said it requires “true grit,” which is also the name of his university’s retriever mascot, True Grit.

One of the most critical points is the first undergraduate science course that high-achieving students take, he said. At UMBC, staff have created a new chemistry center and reorganized the curriculum. It’s also important to upend the cutthroat atmosphere in STEM fields and promote teamwork and cooperation, he said.

As a top institution, Stanford has a responsibility to promote diversity and inclusiveness, Hrabowski told the audience.

“When people look back at Stanford Medicine 100 years from now, who will they say you are?” Hrabowski asked. “The problems we face are more difficult than ever. The challenge is to keep learning and struggling with the issues.”

Previously: Intel’s Rosalind Hudnell kicks off Dean’s Lecture Series on diversity, Former Brown University President Ruth Simmons challenges complacency on diversity and Diversity is initial focus of new Stanford lecture series
Photo by Becky Bach

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