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When the patient is the diagnosis

Even highly trained, dedicated physicians make mistakes, and one study concluded that every year, upward of 12 million Americans (about 5% of outpatient encounters) leave a doctor’s office with an incorrect medical diagnosis. Drs. Hardeep Singh of the Baylor College of Medicine and Michael DeBakey of the Veterans Affairs Medical Center in Houston state their research “suggests about one-half of diagnostic errors have the potential to lead to severe harm.”

Explanations for physician misdiagnosis include incorrect information from patients, too narrow a diagnostic focus, over-reliance on a previous diagnosis, physician time constraints resulting in a hasty diagnosis, failure to order diagnostic tests, ordering the wrong tests, misinterpreting test results, physician stress and physician burnout.

Another factor in medical misdiagnosis is “implicit bias.” Social psychologists Samuel Gaertner of the University of Delaware and John Dovidio of Yale University state these negative, unconscious or automatic (implicit) feelings can differ from conscious (explicit) attitudes. Because they occur without conscious awareness, implicit biases are frequently at odds with one’s stated, overt beliefs.

Physicians are just as prone to implicit biases as members of the general population. Juancye Taylor, chief diversity and inclusion officer at the University of Mississippi Medical Center, states that physician implicit bias can be directed at patients based on their race, ethnicity, gender, socio-economic status, sexual orientation, religion, body weight, physical disability, legal document status and language. Other researchers have added mental illness and patient alcohol and/or drug problems to this list.

Dr. David Newman-Toker, director of the Johns Hopkins Armstrong Institute for Patient Safety and Quality Center for Diagnostic Excellence, states an individual having a stroke has about a 9% chance of being misdiagnosed in the emergency room. However, people of color, as well as females, the young and/or those with less than a high-school education have a higher rate of misdiagnosis. Newman-Toker states that being female raises the risk of physicians not diagnosing a stroke when that condition exists by 30%.

Of all patient characteristics that trigger implicit bias, gender and race have been the most researched. Newman-Toker states that it’s difficult to accurately determine if diagnostic errors are caused by implicit racism and sexism, or these mistakes are made because some diseases manifest themselves differently because of gender, race and age.

According to medical journalist Maya Dusenbery, the age-old notion that a woman’s medically inexplicable complaints “were all in her head” still persists. That is, there is an implicit bias on the part of many physicians to “psychologize” women’s complaints. Dusenbery notes that female patients are often told they are undergoing stress, have anxiety, are suffering from depression and/or their complaints are a result of hormonal cycles. David Newman-Toker states that attributing symptoms to anxiety or stress may well be a fall-back position when a physician is stumped.

Dr. Alyson McGregor, co-founder and director of the Sex and Gender in Emergency Medicine Division at Brown University, states that bias against female patients is pervasive in contemporary health care. McGregor argues that just as female medical complaints were once routinely dismissed as feminine hysteria, today a diagnosis of “anxiety” after hearing a woman’s physical complaints is a “wastebasket diagnosis for the unknown.”

One study found that coronary heart disease symptoms related to physicians in the context of a stressful life event “were identified as psychogenic in origin when presented by women and organic in origin when presented by men.” These findings might explain why there “is often a delay in the assessment of women with heart disease.”

Dr. Joseph Betancourt of Massachusetts General Hospital says “the fact that racial/ethnic disparities in health care exist is now undeniable, indisputable and extremely well detailed.” One likely factor in this disparity is implicit bias. Physicians too often assume their black or low-income patients are less intelligent, more likely to engage in risky behaviors, and less likely to adhere to medical advice than their white middle- and upper-class patients.

Dr. Stephen Strakowski, professor of psychiatry at the University of Texas at Austin, states that African-Americans with severe depression are four to nine times more likely to be diagnosed with schizophrenia than white patients who present the same cluster of symptoms. As a consequence of this misdiagnosis, African-Americans do not get the mood stabilizers their condition requires and may suffer unnecessary side effects from schizophrenia medication.

After examining 15 years of research on the relation between physician implicit bias and the race/ethnicity of patients, Drs. Makini Chisolm-Straker of the Mount Sinai School of Medicine and Howard Straker of George Washington University note, “studies showed that U.S. providers hold anti-black implicit bias negatively affecting patient-provider communication satisfaction. But these studies have not shown this bias consistently negatively affects diagnosis and treatment regimens of black patients in comparison to white patients.”

Dr. Mark Garber, chief medical officer of the Society to Improve Diagnosis in Medicine, states that when dealing with patients who have mental health issues, physicians may be so focused on those issues they may not notice a heart problem. If a patient with mental issues complains of abdominal pain, a physician may assume the complaint is related to the individual’s mental difficulties without testing for organic causes of the pain/complaint.

Dr. Kimberly Gudzune of the Johns Hopkins School of Medicine states that as soon as health care providers encounter patients, “we’re automatically making a judgment about who you are as a person.” One of the first things that comes to attention is a patient’s body weight. According to Gudzune, surveys indicate more than 50% of physicians view obesity as awkward, unattractive and ugly. Doctors have “less respect for patients with obesity. They also believe that heavier patients are less likely to follow medical advice, benefit from counseling or adhere to medications.”

Weight-related implicit bias can result in misdiagnosis. According to Newman-Tucker, if an obese patient complains of back pain, the examining physician may conclude this pain is a function of obesity without considering other reasons for the complaint.

In a recent Washington Post article, physicians recommended what patients should do if they suspect a misdiagnosis or the prescribed treatment is not helpful:

1. Don’t be afraid to speak up if you believe the examining doctor is missing or overlooking something.

2. Dr. David Newman-Tucker advises patients to ask the examining physician, “What is the most worrisome thing this could be, and why isn’t it that?” If the doctor can’t support an opinion or is dismissive of your query, it’s a signal the diagnosis may be a gut reaction to the patient’s symptoms.

3. If a diagnosis is made, a prescribed drug taken and symptoms still persist, it may be the diagnosis — not the drug — that is wrong.

4. Never hesitate to get a second opinion.

It’s impossible to eliminate all of the factors contributing to medical misdiagnosis. However, via the recommendations above, individuals can reduce the likelihood they will be incorrectly diagnosed.

George J. Bryjak lives in Bloomingdale and is retired after 24 years of teaching sociology at the University of San Diego.

Sources:

Betancourt, J. (June 25, 2014) “Not me! Doctors, Decisions, and Disparities in Health Care,” Medscape, www.medscape.com

Chapman, E. (Feb. 15, 2013) “Physicians and Implicit Bias: How Doctors May Unwittingly Perpetuate Health Care Disparities,” National Institute of Health, www.ncbi.nim.nih.gov

Chisolm-Straker, M. and H. Straker (March 13, 2017) “Implicit bias in medicine: complex findings and incomplete conclusion,” American Psychological Association, www.apa.org

DeAngelis, T. (2019) “How does implicit bias by physicians affect patients’s health care?” March, American Psychological Association, www.apa.org

Durkin, M. (February 2017) “Doctor, your weight bias is showing,” ACP Internist, www.apcinternist.org

Firger, J. (April 17,2014) “12 Million Americans Misdiagnosed Each Year, Study Says,” CBS News, www.cbsnews.com

Glicksman, E. (Nov. 18, 2019) “Your diagnosis was wrong? Could doctor bias be a factor?” Washington Post, www.washingtonpost.com

“How 4 types of cognitive bias contribute to physicians diagnostic errors — and how to avoid them” (June 9, 2017) Becker Hospital Review, www.beckerhospitalreview.com

Marini, M. (May 23, 2019) “Does Implicit Bias Affect Clinical Decision Making?” Psychology Today, www.psychologytoday.com

Seegert, L. (Nov. 16, 2018) “Women more often misdiagnosed because of gaps in trust and knowledge,” Association of Health Care Journalists, www.journalism.org

“Study reveals that signs of heart disease are attributed to stress more frequently in women than men” (Oct. 12, 2008) Eureka Alert!, www.eurekalert.org

Taylor, J. (March 20, 2019) “Unconscious Bias in Health Care Setting,” The University of Mississippi School of Pharmacy, www.pharmacy.olemiss.edu

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