Remember that patient you saw the other day?... Misses and traps in emergency presentations
Jess:
Welcome everyone to the latest instalment of our Rural Health webinar series. My name is Jess Ledwidge, and I will be hosting tonight's webinar. This webinar will explore emergency signs and symptoms that are easily missed and explore how rural and remote GPs can identify and manage these tricky presentations.
Tonight's webinar is facilitated by Dr Geoff Couser, an emergency physician at the Royal Hobart Hospital, who has interests in medical education and low value care. Dr Couser developed emergency medicine as a discipline at the University of Tasmania, and is the clinical lead for Choosing Wisely for the Tasmanian Health Service.
If you could just go the next slide for me. Thank you. We would like to begin by acknowledging the traditional owners of the lands that we are coming together from this evening and on which this event is being broadcast. I would like to pay our respects to their Elders past, present, and emerging and I would also like to acknowledge any Aboriginal or Torres Strait Islander people who have joined us this evening.
We will just move on to a few housekeeping things. Participants are set on mute to ensure that the webinar is not disrupted by any background noise, but we do encourage you all to use the chat function or the Q and A function to ask questions. When you are using the chat function, please address your questions and comments to all panellists and attendees rather than just to the panellists, so that everyone can see your questions and comments coming through. And finally, this webinar has been accredited for one hour of CPD as an educational activity. To be eligible, you must be present for the duration of the webinar.
We also kindly ask that you complete a short evaluation at the end of the webinar. This should only take a few minutes, and will help us improve the format and content of future webinars. We will just move on to the next one.
So before we begin we will just talk a bit about what you are going to get out of the webinar. So by the end of the session participants will be able to recognise that diagnostic error is a common occurrence, describe how common factors and biases can lead to diagnostic error, recognise that many diseases exist on a spectrum of severity, and how this can help recognise the potential for deterioration, and finally, describe the physiological responses to illness which can be used to identify the early stages of serious illness. But for now I will hand over to our facilitator for this evening, Dr Geoff Couser. Thank you, Geoff.
Dr Geoff Couser:
Thank you very much, Jess, and good evening all, and welcome from lutruwita, Tasmania. I am in Hobart this evening. And I hope you have all had a good day, and you are having a chance to either have some time out over Easter, or as is so often the case for us in the health service, getting ready to work even harder than usual, as fewer and fewer other services are around. So tonight, when I was asked to do this webinar, and to come up with a topic, I thought looking into near misses, and how we make diagnoses, and how we miss diagnoses would be an interesting topic. If anyone knows me, you know that over the last few years I have been very passionate about talking about low value care and about over-diagnosis, and how that can impact upon good medical practice and the impact that can have on our patients and on the broader system. But once you look into that, the other side of that same coin is diagnostic error, and the very fraught landscape we move in, with increasing pressures upon us, system under pressure, more and more patients being treated and managed by fewer and fewer practitioners. It is very hard to practice good medicine sometimes, and as an emergency physician in public practice, who travels out to Alice Springs once a year and works in my own hospital at the Royal Hobart Hospital and doing a little bit of telehealth on the side, I am really quite aware of just how, it really is a mine field out there.
So I wanted to start with a few inconvenient truths, and also maybe even a disclaimer. And I think many of you will be able to recognise this, but the disclaimer, and I did not really want to put it in writing, because even though it is encouraged that we should be up front, and it is very hard to talk about things, it is very hard put it in writing. But look, I have made so many mistakes. I have been doing this for 31 years now, some of you would have been doing it for longer. But I have made a lot of diagnostic errors in my time, and I have sent patients home who have come to grief, who have had a morbidity or mortality as a result of me making a diagnostic or a management error, and I think we all have. But the important thing is to look into the broader system, and how we can reduce that because we acknowledge that we are human, and it is good to know about some of the factors out there, and that is what I want to explore tonight. But it is interesting, once you start exploring some of this, it really is a rabbit hole that you can just go down further and further and further, and I do not want to just bore you with a whole lot of talk about the biases, because I do want to bring it back to clinical experience. And actually for me, suddenly realising that might almost be a bit of a, bring it around by understanding the physiology and understanding the pathophysiology that drive our body's response to illness and stress, and if we can detect that, the subtle signs of that, that can actually be very helpful when it comes to recognising the future that may or may not occur.
Also, feel free to make any comments in the chat or the Q and A boxes. I have got them open on my screen here, and if I can respond at any time I will do my best to. But look just a few things. I just did a bit of a brain dump, and look, despite talking about diagnostic error and talking about, you know, bad outcomes and things there, for most things, common things do actually occur commonly, and most presentations are not acutely serious, and we do manage things quite well. Emergencies are subjective. It is kind of the patients who decide what is dangerous. They may present to us early in the piece or way too late. And you know, despite you know, hoping that maybe with the internet people would get better health literacy. Well, how is that going? I do not think it is really going all that well, and I was hoping that you know, sometimes patients could join us on this journey of having that shared care and understanding health outcomes. But the internet has not really helped there a lot. And despite all this, we make it very hard for patients to access the health system. It is very difficult to access, and once you are in it, to navigate it, it is even harder. And despite all this patients come to us. They do not go to Kmart. They do not go to JB Hi-Fi. They come to your GP practice. They go to the local hospital or clinic. They dial triple zero. They access the health system. And to quote my old friend Bryan Walpole, who many of you might know, he was the director of the emergency department at the Royal Hobart for many years, he said everyone has a terminal event, just don’t you try to be a part of it. So that is worth just bearing a mind. So that is kind of how I want to open the discussions here. And I am sorry my mouse is a bit too sensitive.
So there was a really good paper by Ian Scott and Carmel Crock in the MJA back in 2020. It is only a short paper. It is really worth digging up, and it talks about diagnostic error. And to be honest, it is a bit surprising that we do not look into this a little bit more than we do. It is only been in the last 10 years that we have started to look at over-diagnosis and low value care. I think this is probably one of the next things we are going to really try and look into and try and build up systems to help us. But just to put it in perspective, you know, in up to 14%, one in seven clinical encounters, there is a form of diagnostic error. Sometimes, you know, 140 thousand cases get on the radar every year which can lead to significant cause of serious harm and deaths. Bad news, almost one in two malpractice claims against general practitioners involved diagnostic error. More than 80% of these errors are deemed preventable when we have a look at it, and the bottom line is that cognitive factors tend to be the issue. The stuff that we tend to worry a lot about the system errors, you know, that follow up, or you know, the timing of laboratory tests and stuff, they are less, of a cause. And in fact, talking to colleagues, you know we spend a lot of time, I do not know if you do as well, talking about things like the timing of troponins for example. Someone who has chest pain, when should you do that troponin? Should you do it at two hours, should you do it six hours? Almost no diagnostic error as a result of a mistimed troponin. Sure there are some. But the big thing is not even thinking about the chest pain, and in the group who you might not expect to have an acute coronary syndrome. So they are the issues that we need to understand, and we need to unpack.
And when we look at diagnostic error there are three main factors, and that is understanding that diagnosis is complex. We are humans, and we are fallible. And our health care systems are imperfect and error prone. And you really do have to wonder, if you were going to go and diagnose a health system in 2023 would we diagnose one that looks like the one we have got at the moment? And sure by world standards we do very well, but there are horror stories out there everywhere, and you know you get the Avant newsletter, and you know, you think gee whizz that could have been me.
So let us have a bit of a closer look at some of these. So diagnosis is complex. This was fascinating, reading this. Two hundred symptoms, but over 10,000 diseases, and we cannot cover it all in medical education. Common conditions present in a variety of ways, and as we said, emergencies are subjective. Patients do not present when they well, you know, we try and catch them and keep them well, and recognise these things, but so often they present when it is too late or when they are hurtling towards an almost inevitable outcome. And the bad news, rare diseases, are not really all that rare. So we are expected to have a knowledge, or at least know when or how to access more complex knowledge. Once you find a rare disease, trying to find somebody else to share that interest is also very hard from a referral perspective.
Human cognition is fallible, and these are the sort of things that I want to talk about. You know, most of the stuff, you know, I do not know if anyone has read Thinking Fast or Slow, you know, the authors that got the Nobel Prize in economics, talking about how they think and how we make decisions. But hardly anyone has read the book. I have got it on my bookshelf, and that is where most people have it. But it is talking about critical thinking that type one, you know, the gut feeling, the heuristics, and the type 2 is more that drilling down and thinking about it. But we are not really all that good at making decisions, and I do not know about you, but most of my registrars, residents, medical students really hate uncertainty. And this is what I want to talk a bit about, is we do bring a lot of biases to our decision making, and as long as we recognise that and understand that we can work around it. And look, the next thing they talk about, you know, production pressure, interruptions, distractions, fatigue, illness, burn-out many other factors, they really impact upon us. And you know, I am sure you have all been like me when I was in my emergency department last Friday night at midnight, when there were 80 patients in the department, about 35 were unseen. It is full resuscitation, I had no room. The junior stuff coming on for overnight. I thought I cannot really leave them now. There it is, you know. But then you look at it and you think this is really fraught.
But then also we should celebrate things too. This is not all bad news. I like to sometimes look at what we do, and go, far out, how do we get this right so often? So do not feel so bad about all of this. We are actually doing fairly well, but we can do better, and that is what I really want to talk about. And also talking about the health care system, you know, break downs in front of the diagnostic in every step of the process. And I think we all recognise with this that you know, things such as safety monitoring systems improvement, are usually secondary below that, you know, this refers to financial stability and productivity, but quite frankly, all of us, I think, and barely just keeping up with what is in front of us, and the next patient coming and the next patient after that, and we are just barely keeping up with that, let alone taking a step back and going, geez it would be really nice to have a morbidity and mortality meeting over lunch on Thursday, just to go through things. But you know, that is the system we are in, and so we have to acknowledge it, recognise it, and we have to deal with it and agitate for change.
And also that patient-practitioner clinical encounter. It is such an interesting thing. I do not want to turn this into just a big whinge fest, you know, but I also do really recognise and feel sorry for a lot of my colleagues in primary care, who governments seem to think that you could just you know, tap you guys out and put in a pharmacist just to do a script and to do things. But we know that this diagnostic error is a thing, and it is related to a breakdown in that process of the clinical encounter, and so making it even more fragmented, even more ephemeral and transient, I am not sure that is necessarily a good idea.
And then every now and then, sorry I will stop ranting. But then you turn on the 730 report, and you got Dr Foe, or whatever her name is, talking about how all of us in medicine are just in it for the money. Yes, let's not even talk about that. But it is fraught, and our health systems are imperfect.
Now doing some research, there is an Australian version of this, the Society to Improve Diagnosis in Medicine. Caramel Crock, who is the Director of Medicine at the Eye and Ear Hospital in Melbourne is driving a lot of this. But you know their analysis, you know, one in three cases, you know, is due to misdiagnosis, and relate to malignancy, vascular events, and infection. And when I was reading this, I had a bit of an “a-ha” moment, and I will come back to that. But that is, I think, really, really quite important.
Before I get into it though, and this is out of the Ian Scott and Carmel Crock paper out of the MJA in 2020, it is just a nice little overview of some the biases that are out there. And I will let you just have a quick read of that screen while I have a little sip of water, and then I am just going to go into some of these in particular, just one by one, and give a clinical example. And I would like you to just sort of think about where maybe you have almost been caught up by this, or where you feel that you have perhaps been subject to that these sort of biases, because we all have them, we really do. So let us have a bit of a look at these one by one. So premature closure. I will just move my thing over. My things are blocking my own slides. So that is you know, where we focus on a few clinical features, and then we go right, this is what is going on. And I have to admit we in emergency medicine, particularly well, whilst we do get it right most of the time, our labelling a patient with something very quickly can have long-term consequences, because people do get focused on that. And it is very, very hard to pull out of this diagnostic funnel once we are going along that. And the example here is, you know, a patient with rheumatoid arthritis who is on immunosuppressive medication, shortness of breath and respiratory crackles, and, you know, has a chest x-ray that could look a little bit like pulmonary oedema. But you know, we say congestive heart failure, but then sparks a temperature down the track, and then realises that you have actually got a patient with pneumonia and sepsis. And you know, we can say, oh, you know, of course I would recognise that with a patient who is immunosuppressed. But you know, patients present with very different symptoms and signs all the time, and it is important that we acknowledge that, and we need to keep an open mind and avoid that premature closure.
So anchoring bias, you know, we cling to our initial diagnostic hypotheses, and that is sort of related to that initial one of premature closure. In an end stage renal disease patient with altered mental status and myoclonus, and we think all that is the uraemia. But then, despite other things coming, we, you know, finally accept that maybe there is seizure activity going on there that we need to deal with. And so we do tend to hang on to things, and so that anchoring bias is an important one, and I think there is no shortage of things where we have all done that.
Confirmation bias is an interesting one there. We see confirmation bias probably based around almost in everything we do, not just in medicine. It probably comes down to whether you read the Australian, and you think that the Liberal National Party is really just getting it right, and it is everybody else who has got it wrong, or you read the Guardian, and you sort of on the other side of everything there. So we all tend to like our confirmation bias. We are all very good at looking for evidence that supports our pre-existing ideas. It is very, very hard to have a true open mind, and to get out of our own echo chamber. But, for example, this is one that has come in, you know, with coeliac disease, is anaemic and is organised with iron deficiency anaemia. Iron studies are interpreted as confirming that. Again, you are heading down this diagnostic pathway, and you sort of ignore other things that might appear in this particular patient, who was diagnosed with a thymoma with aplastic anaemia. You know again, it is not the most common thing out there, but it is an example of how confirmation bias can take us down the wrong route there.
Similarly, representative bias. Overestimating the likelihood of a rare diagnosis. One of the things we get in now emergency department, I think everyone does, you get the radiologist going, you realise that cauda equina is actually really rare? But you guys seem to think a lot of people have it, and that is why you are ordering these urgent MRIs. You could probably draw a bit of a graph related to sure it is low incidence, but it is high significance, and it is significant if you get it wrong. And certainly if you see somebody with cauda equina, or you see somebody with an aortic dissection, or you see somebody with a subarachnoid haemorrhage, that tends to affect you further diagnoses, you know beyond that. And similar, you know that pheochromocytoma is out there, but you know, other things are more common. And, as I said at the beginning, common things occur commonly. Which does not make it easy. But these are biases that we need to need to acknowledge and deal with.
Probably one of the most important ones, and I just want to talk a little bit about this because this is a source of significant morbidity and mortality, and that is the framing bias. Now this is where the presentation of a patient puts us in the mindset and we make a decision, or we are influenced to make decisions based around the way they present. And you get that diagnostic momentum based on their past history or the setting that they are in, and whether it be somebody who is brought in by the police with an acute psychotic episode, or whether it is the police bring somebody in from the jail cells. We tend to have that framing bias, and I will talk about a particularly significant case there.
So there is a question there. Why did the coeliac disease with iron deficiency anaemia have a chest x-ray? Oh, look, I am sorry Dr Chen, I cannot really tell you that. It is an example, so we will just accept that as part of somebody's diagnostic workup they had that. But in this particular one, somebody with long-standing anorexia nervosa with weight loss, abdominal pain and diarrhoea, one thinks that it is related to mental health leading to a diagnosis of irritable colon and the laxative misuse. You know so far so good, but still intermittent rectal bleeding and iron deficiency anaemia are under emphasised, and eventually the patient is diagnosed as having a bowel cancer. And there is a lot of similar stories of that related to patients who are, you know, younger than you would normally expect. Certainly males in their twenties and thirties. Females in their twenties and thirties certainly can get bowel cancer, and often when you look into it, there is that long history of bowel symptoms that have been put down to something else, probably largely because of a framing bias that exists.
The two I really wanted to talk about with framing bias, you know, these forensic and psychiatric presentations. They are particularly high risk, and one of the real big risks out there differentiating the psychiatric from the medical, and I will talk about that a little bit later, and marginalised groups, particularly at high risk, and the case of Ms Dhu in Western Australia, back in 2014, where basically the system did fail her in various places, in the justice system and then in the health system. She was just framed as you know, being a troublemaker and being in jail when, in fact, she was developing sepsis, from which she ultimately died. And it is really quite a sobering coronial report to read. But that is a case of framing bias, and that is something that we do really need to check.
So what can we do to reduce this error? Well, reading and education is really important and just, you know, these were just sitting on my desk when I was putting this together from our Emergency Medicine Australasia just a couple of months ago, misdiagnosing aortic dissection, and the Avant newsletter there, you know, talking about, you know, coroner fixated thinking behind a case of an oesophageal intubation. And so it happens everywhere in the system. And they talk about some strategies, and that is certainly quite important, you know. Be mindful of making assumptions. Keep an open mind. If it is stressful, just take a deep breath, and just try and clear the mind. And you know, as I was saying, I work in emergency medicine and things get crazy at midnight, so not only am I tired, my mind is full and it is really hard. And also creating a culture where you can have the junior doctor or the nurse, even the clerk, anybody, just say, look are you sure about this? And so encouraging people to be able to speak up. And there is a program, Speak Up for Safety, which is about creating that culture where you know, we can try and avoid things. If somebody perhaps in that police cell with Ms Dhu sort of felt that they could say, hey, this is not quite right, she does actually look quite sick, perhaps we should get her checked out and emphasising that to the hospital, we can overcome these biases that we recognise.
So some of these strategies, and I am going to get on to some clinical things shortly, you know, as I said, the more I dug into this, the bigger it gets. But you know education, acknowledging it and recognising our own biases. They say diagnostic checklists can help, and that is certainly something that we do try. We certainly, when we are doing airway management, you know, using the vortex approach and an airway checklist, that is really quite helpful, because I am an occasional intubator. But then again, airline pilots go through the same checklist every time they take off, and even though they might have taken off, you know, thousands of times, they still go through the same checklist. You know, cognitive forcing strategies, deliberate practice. Now, these are all things that are quite interesting, but it occurred to me that some of the most simple things we can do is when we actually make clinical notes, I mean this has happened to me where you sit down, you have seen a patient, you are writing a note, and then you go, a-ha, this is what is going on, because that is that forced reflection, as you are writing that note, and whilst you are talking to the patient, it may be that it is a bit beyond you, or you are thinking, hang on, I cannot make sense this, or this could be that. But then when you see it written down in front of you, this is a forced form of feedback, which is why I am a bit sceptical about some electronic health records where it is almost to tick the box, or where the patient does that, because writing notes is actually that forced slowing down to actually reflect. And I think it is underestimated.
Seeking second opinions and having systems within your own practice. You know, one of the things I always say to my junior staff, I said, look, please, if you think I have got it wrong, just say so. You really do need to tell me, you know, because as I said, I have been doing this 30 years. I get a bit tired around midnight. I do not always get it right, and sometimes I might have said something really stupid, and I did not even realise it. So if you think it is something, anything, just to say, hey, Geoff are you sure about that? And having morbidity and mortality meetings built into the system is actually really useful, and having AHPRA is actually, you know, mandating that this reflected practice is part of our CPD. It is probably easier said than done, because when you are just again dealing with the mania and the craziness of every day practice, it is very hard to do this sort of thing.
Computer assisted diagnosis is something that is getting a lot of talk out there. I did think of asking Chat GPT to put this talk together for me, but I can assure you this is all my own work. But I actually asked them the other day, has anyone played around with some of this AI stuff? It is quite interesting. I had a spare moment in our short stay unit the other night, and I had this patient come in with a UTI who was just a little bit wobbly, and we were going to just get him started on antibiotics and get him seen by our aged care team in the morning, and if he got better, then I would send him home, if he did not, we would admit him. But I wrote in the Chat GPT write a two-page medical admission to a short stay unit for an 83-year-old male with a mild delirium secondary to a urinary tract infection, and in literally about a minute, it wrote as good an admission that I could have written in about 15 or 20 minutes. I was actually blown away by it. Anonymous. Yes, using Chat GPT to summarise your raw notes into a referral letter. Seriously, good on you. Wow! That makes sense. Tell me, does it do a good job? Does do it better than you? But I mean, does it free you up? Is it a bit of a form of cognitive offloading? Which means you can get Chat GPT to do that while you go and do something more higher value like seeing the next patient or reflecting? But not good on you.
But using clinical decision rules. We kind of get drawn into a lot of these, and I am big fan of, you know, I have got the app here just the MD Calc, which has got all the clinical decision rules. And we would like to think that clinical decision rules are the manifestation of evidence based medicine into something practical for us to use at the clinical encounter. But a lot of them have not been validated, and a lot of them really are not any better than our own vibe, the gestalt, and also to be honest our own biases, all the biases I have just talked about having brought into those very same clinical decision rules. And so you know, that is the challenge about AI, but they are flawed, and probably one of the best things to do is just to acknowledge your vulnerabilities with our patients, and just having some humility and just saying, look, this is the most likely thing. But you know this is a possibility. And we call it safety netting, but this is when other things come in, we are over-diagnosing and over-investigating. We have to be really careful we do not just create a form of care signalling, you know, virtue signalling where you know you post on Facebook that you are sponsoring a child in, you know Africa, or something like that. We have to be careful we do not say I am going to do all these tests to send a bit of a signal to our patients that we are doing something, but knowing deep down that they are actually not adding any value. So it is really important that we get it right, and that we only do what is valuable. So as I said, you know, low value care, avoiding error, doing appropriate investigations. It is a very fine line, and I acknowledge it is really, really hard, particularly in this current environment that we are working in.
So we have to understand where we are in the scheme of things. And I have to resist putting in an Alone plug which is being held here, and you know, which was filmed in Tasmania last year on SBS on Wednesday nights now. Oh, my God, anyway. But we are sometimes, we can be very alone, and we have absolutely no idea where we are. But I am going to put forward for those of you who, I think Jess said she saw me at GP 22 in December last year. This slide largely informs all of my practice, and the way I think about things. And we can talk about it on a macro level. We can talk about it on a micro level. So at a systems level, I really respect people in primary care who are working up here where patients are in homeostasis, where they are in equilibrium, and you are keeping that diabetes under control, getting them to stop smoking, looking after those statins, maximising cardiovascular health, respiratory health, all that good preventive medicine in primary care. And patients live up here, staying in their usual residence, and we never see them in the acute hospital system unless it is a really off the site thing. It is unsexy. It is invisible. People do not see what you do, but yet it is cheap, it is effective, and you need better marketing. That is what I think it comes back to. I work down on this side of it where really it is not that hard to recognise sick people, because by the time they get down here, and whether it be self-presented or for whatever system is there, they are presenting acutely to an emergency department. And it is really quite hard to get people back to that usual residence or rehab, because without great expense, time and effort, and a huge amount of frustration, you know, much better to have airbags and good roads, and not drive when you are drunk, or using your mobile phone up here rather than smashing into other cars and being brought in as a major trauma case here with massive morbidity and mortality. But there are a lot of other things here, and this is also a physiological curve where you start getting some early signs up here where, if we are smart, and if we are in tune with our patients, we can detect it. Then it becomes a bit more obvious and we are able to do it, but by which time the horse has bolted, the ship has sailed and we are getting into trouble, and it is getting harder to get that. And that is what I wanted to talk a little bit about now, because there is a lot going on here from a physiological perspective and the diagnostic error perspective.
So just a few of the conditions we see. Just look on the left hand side there first. So think about chest pain, collapse, sepsis, mental health emergencies, malignancies. So think about chest pain and some of the unusual presentations. Chest pain, you know, women and young people still do get significant amounts of chest pain. Women in particular, whilst they do have considerable cardiovascular mortality, we tend not to treat them the same as we do with, you know, men who are, you know, myself, a 54-year-old male getting chest pain, you would take very seriously. I had a 34-year-old woman last week with not that much in the way of risk factors who had some atypical chest pain. Not quite a, you know, normalish ECG, who I thought, well, let us give her some aspirin and let us just check her troponin, and then her troponin came back extremely elevated, and you know, those biases could have led me somewhere else with her.
A patient with syncope. And you know I will talk about this on the next slide. As an example, it is a spectrum of the same pathophysiology. It might be nothing, could be something. Similarly, sepsis. Early sepsis I vague, non-specific symptoms, but can very rapidly become overwhelming. Mental health emergencies. It is so much better to keep people well out in the community with all those services that exist. Yes, they are not quite there, are they? Instead of them being dragged in by the police and ambulance, and me having to use five people to restrain them, so I can safely sedate them and assess them and then keep them in my emergency department for four to five days, waiting for a mental health bed. And many malignancies, you know, they have early signs, but as I have talked about, our biases may prevent us from recognising that.
Now the thing I want to say, just remember the cases that are due to misdiagnosis. Cancer, vascular events and infection. That is your chest pain, collapse, sepsis and cancers on this thing here. These are on a spectrum, aren’t they? They could be a little bit of chest pain, or could be the massive ST elevation infarct with a cardiac arrest. The collapse could be a bit of syncope, could be right through to a form of shock, cardiac arrest and death. Sepsis, mild bit of illness, starting to get a bit sicker and sicker, and then you have overwhelming septic shock. Malignancies, as I said, early signs, presenting late with metastases and a poor outcome. These are the malpractice cases, but they are all also cases that exist back on this line here. We can either diagnose them up here where we can overcome those biases that I was talking about and look for some subtle clinical clues to recognise that maybe they are about to go down here. Or we can ignore those clues, and you know, do not address the biases, and then they get picked up down here. And so these cases, which are the big causes of misdiagnosis and medical litigation are on this slide. And again, I just threw a few other things out there as well. You know, abdominal pain, worse than clinically suggests, ischemic bowel or is there volvulus? You know they are still out there. Syncope, as I said, the unexplained tachycardia, could it be a PE? Chest pain in women, abdominal pain in women, the ectopic pregnancy, ovarian torsion, endometriosis. We treat women terribly with abdominal pain endometriosis and acute coronary syndrome in our health system. Change in bowel habit in young men.
Behavioural disturbance. So I mentioned this earlier, the differentiating the psychiatric from the medical. Excuse the language, but I learned this when I was a young medical student, and patients with behavioural disturbances, you know, mad, bad, sick or pissed. And it is still kind of a useful little thing I go over in my head. You cannot just assume that somebody coming in who is quite, you know, behaviourally disturbed, has got one of these particular conditions. You do not just assume because they have been brought in by the mental health team, they have got a psychiatric condition. They could be psychotic. They could be acutely manic. That could be why they are behaviourally disturbed. But they could also be a bad person, bad people do get brought into our practices, and we have to differentiate them from the sick or the intoxicated or the psychotic, so we can say to the police, I think this is a forensic issue.
But patients do present sick. And we can come up with any number of reasons why someone might present with an acute behavioural disturbance. It could be that they could be hypoxic. They could have a sodium of 108. They could be septic. They could have a brain tumour, they could have had a brain injury and have a mass effect. They could have an acute endocrine disturbance, they could be thyrotoxic. There could be any number of things. Or they could be intoxicated. They could be intoxicated from drugs or alcohol, or they could be withdrawing from drugs or alcohol. So it is important that we do not have that framing bias, and that we actually try and overcome that. And one of the most important things is to actually check the vital signs and certainly understanding, but you know, just getting a temperature, you know, pulse rate, respiratory rate, is really quite an important fundamental issue there that we need to consider.
Now, I just wanted to talk about syncope. And syncope is something I have talked about quite a bit over the years as an example of this, but I just want to reiterate it. So again, going down the left hand side. If you think of syncope as a spectrum of that same pathophysiology. And I am going to take you back to your early years of your medical school here there, and that you have got pre-syncope. You feel a bit light headed, but then you come good. So your baroreceptors and your carotid arches your aortic arch. Recognise that for whatever reason there is just bit of reduced cardiac output. So they send a message down to your adrenal glands. A little bit of catecholamines get released, and you have got some vasoconstriction. Your heart pumps a little bit faster, and you still have a perfusion to your brain, if you do not pass out. Syncope, the next level on that, you pass out. But then that same feedback loop kicks in and restores perfusion to the brain, things get okay. If you do not recover, if you do not restore your blood pressure or your things there, you have got actual shock and going into the pathophysiological causes of that, you have got hypovolemic, you have lost volume for whatever reason. And there is any number of good reasons for that. Cardiogenic. You know, your heart is actually failing, and you cannot perfuse. You have got obstructive shock. Your heart would love to pump, but it just cannot, whether it be due to a massive PE, tension in the thorax or pericardial tamponade, or you have got a distributive shock whether, you know, it be due to anaphylaxis, you know, where you have got that massive dilation, and you have got leaky capillaries and loss of that intravascular volume because of that. Again, if that does not work, and it is decompensating, you then move to cardiac arrest, in which case you have got to go through and try and make somebody who is dead make them alive again. And if that does not work you are actually dead. And if you think about pre-syncope, let's label it as everybody in shock and along this spectrum, as we are going down that curve that I showed, pre-syncope is at pre shock, you know, you are on top of it quickly. Transient shock you do compensate, but you pay the price of passing out before that fully kicks in. You have got your actual shock where you have got physiological decompensation. You have got ultimate shock, which is cardiac arrest and death is, of course, irreversible shock the ultimate no perfusion.
So, understanding all the processes that are happening here, the baroreceptors are happening there in a few seconds. If you got under perfusion that is still persisting despite that, that is when your angiotensin system kicks in. You know, your kidneys recognise that there is that reduced perfusion coming through, and so they send out bit of aldosterone, angiotensin too which is a potent vasoconstrictor. And then, if it is still going on for a few hours you have got, you know, release of anti-diuretic hormone and effects up in the pituitary where it is sending out a longer term thing there to deal with that. So all of these basically is where you have got syncope, and causing all sorts of things on that same spectrum, but it is up to us to be able to recognise this early. And you know, for example, sepsis could be something going down that pathway. You could have somebody who is hyperventilating. You know, the reason they are hyperventilating when they are unwell is they are developing that under perfusion and your body is generating lactic acid. It is an anaerobic metabolism, and you are developing a metabolic acidosis. So you are breathing it off to maintain some form of equilibrium, but often that hyperventilation might be the first thing that actually gets noted. Tachycardia, a sympathetic response, it is starting to kick in a bit more. And because you have got this adrenaline being released, you have got the patient very anxious. That is the adrenaline speaking. So listen to it. And so again, that might be up the top of the curve. By the time they get further down the curve, where they are quite decompensated and unwell, it is often a little bit too late. And you know, the Sepsis Kills program that was run out of New South Wales a few years ago was really quite helpful, you know, that we need to recognise it, that we resuscitate and we refer. But the best thing to do is what we are doing at the front door is recognising it early at the top of that curve and being able to understand the physiology, that we can actually step in and recognise these things early.
This paper came out of the MJA in 2008, The Respiratory Rate: The Neglected Vital Sign. So, understanding that physiology is really important, that we actually do recognise that this is a subtle sign of impending deterioration, and there may be no clinical signs of the actual sepsis or the actual underlying cause of the deterioration. But by recognising the respiratory rate, we recognise the compensation, we recognise our body’s physiological response, and that is what is really critically important. Sorry my voice is starting to get a little bit funny. I am not speaking for too much longer.
So just understand that by recognising these conditions that exist on a spectrum, not only are they a cause of diagnostic error, but we can understand where the patient is on this to be able to keep an open mind. You know, it is easy to have premature closure when the patient presents with a temperature of 39.5, a pulse rate of 120, a respiratory rate of 36, and you know, blood pressure of 80 on 60, and crackles all through the left lung. You have got somebody with the respiratory sepsis and septic shock. But it is another thing to recognise somebody when they might have a bit of a cough and a bit of a fever. But are they developing sepsis? Are they starting to slide here? But going back to the causes of, you know, the big triggers of malpractice and misdiagnosis, it is the infections, it is the sepsis, you know, it is the cardiovascular. These are the things. It is the cancers. So let us pick them up here before they get down here. And look for those subtle signs.
So in summary. Look, people do not have bad outcomes because somebody did not do a heroic act or something, they have a bad outcome because somebody did not do the basics. So let us be brilliant at the basics. Let us be aware of our biases. Let us understand that patients come from different sources. They come from different, through no fault of their own from a lot of socioeconomic groups, who has found themselves on the wrong side of the justice system. They can still get sick. Understand that psychiatric patients do present late in their disease, in their conditions. They have a higher instance of a lot of conditions, and they do present in different ways due to, they may put an overall emphasis on a painful left arm, and the reason I am doing that they may not even be bothered by the central crushing chest pain, you know, and the sweating. But they are focused on one particular symptom. So we have to recognise our biases.
Understanding the physiology reveals important clues. I cannot emphasise this enough. By being able to recognise the beginning of physiological decomposition, that is absolutely critical. Be aware that uncertainty exists everywhere and that we are working in an imperfect system. And certainly feel free to seek help from colleagues, from the patient. Try some clinical discussions, because sometimes they may just tweak an idea that might help you go down somewhere that you were not going to go, and that is really quite so important. But just, I will say to summarise, it is very hard out there. Sometimes I feel that the coroner does not really appreciate just how hard it is. But when we do actually have the time to sit back and look at these things, we can recognise some common themes, and it is a failure to acknowledge biases. It is a failure to recognise those early signs, and if we can just be aware of those, then that is a good thing for our patients. It is a good thing for us. It is good thing for the system as a whole. But then, again, maybe it is better if we just so bush walking and clear our head and get the cobwebs out that way. That might be the way to go.
So that is it for me. Does anybody have any questions, or want to challenge or raise any issues, or anonymously share any experiences that this might have triggered, or thoughts at all? Looks like there is some things coming down on the Q and A. Chris makes a comment. Sorry, tripping over my lips. It is important to remember the diagnoses like gastro, migraines, irritable bowel, are a diagnosis of exclusion. That is, you have to make sure there is nothing more serious going on before you make a diagnosis. I think sometimes the concept of a diagnosis of exclusion is not emphasised enough in medicine. Absolutely, and migraines are a massive trap, aren’t they? You cannot diagnose a migraine on that first headache, even though it might be a migraine type headache. And so you have got to be really careful and look for those, you know more, you know, significant things going on there as well. It is really quite important. But how far do you take it as well? Does that mean everyone gets an MRI, or do they get a CT and a CT angiogram and a lumber puncture? I mean, this is really, really tricky, and that is why, you know, considering a lot of these things. Yes, but no, it is tricky. Actually, I was talking about this to some of my registrars the other day, and they just said, so is it a misdiagnosis if you do not make the diagnosis there and then? Because sometimes these things take a period of time to make a diagnosis, and I think that is an important comment, and I think that needs to be done in a safe situation. I mean, it may be that you are working out somebody who is a high risk chest pain. You need to either do it as an inpatient, or if it is low risk, you can do it as an outpatient. But I think the, sorry I am really tripping over my tongue here. The nomenclature has changed. It used to be, you know, a non-ST elevation myocardial infarction, whereas now we talk about a non-ST elevation acute coronary syndrome. And so, recognising that it is over a period of time, and that some of these patients can be worked up as safely as an outpatient. Some need to come into hospital. Sadly, I sometimes find the differentiator is whether they have got private insurance, but I realise that is not an issue in regional Australia.
Daniel McCubbery has made a comment. There was an Avant case recently where a telehealth consult resulted in a diagnosis of gastro and missed the bowel obstruction that led to a death. Yes, look, you know, as I said, I am doing a bit of telehealth, providing support to regional Australia after hours, and it is fraught, you know, you really got to make a lot of assumptions. The symptom was emesis without diarrhoea. Oh, yes, I read that. Yes, emesis without diarrhoea. Yes, I think without the diarrhoea, you know, whenever I am dealing with a patient like that, you always do ask, you know, do you feel a bit bloated? Do you feel as if you know, that there is anything else going on? And you find that you also do a lot of safety netting, and you know, you have got to sometimes see how these things pan out. And again, you know, saying, look, let us give this a couple of hours, and see how you respond to that. If that does not settle, then we need to again, maybe go back to the beginning and work out where we go. But yes, it is really tricky, particularly if you cannot just go and use your physical examination to confirm or rule out some of your hypotheses.
David Fang, you have asked, what is the difference between clinical reasoning and critical thinking? Can you please explain? Not in the next two minutes, I do not think. This is a huge topic, David. But certainly I would recommend some good links here. I would recommend you having read of that 2020 paper, The Diagnostic Error. It all disappears, doesn’t it? In the MJA, which is a really good starting point. If you just Google diagnostic error 2020 on the MJA site, you will get this paper. And it is only literally four pages long, and that is sort of a lot of the basis. But it has got about 50 or so references if you want to do more of a deep dive into this. But also things like the Society for Diagnosis in Medicine has a lot of resources and webinars that if you really do want to look into this I would urge you to go down there and check out a few things.
The Elaine Bromiley case. Can I urge everyone to go and Google “no such thing as a simple operation”. I think that is what that was called, about basically where the anaesthetist kept trying to get an airway, and the ENT surgeon was waiting outside and could have easily gone and done a neck thing. But yes, the Bromiley case, it is “no such thing as a simple op” or a simple procedure. It is heartbreaking, but there is a lot to learn from that.
Probably we are going to need to finish up, I think, Jess. But Prydna is saying you had a very annoying experience with chest pain, sent to a private ED, condescending letter back saying troponins stable in the context of chest pain for a week and palpitations, but it is not cardiac, in a high-risk cardiac patient with known LAD lesion, sent home without cardiac review. I mean just reading that from the start. If you have got a patient who has got a known LAD lesion, there is no diagnostic dilemma there. This is a patient who has got ischemic heart disease. It is not a dilemma. There is no diagnostic thing. That is a patient who is high risk, automatically gets a look in the door. I will not say too much more. That looks like you are doing the right thing. I am glad the patients doing okay, though. But certainly you do need to write to the ED there.
How Do You Think is a great book. Telehealth terrifies me. Yes.
Any books or websites? Yes. Society for Diagnosis in Management. Yes, I think GPs are experts in managing uncertainty. I do not know what this is, but we have time to figure this out. Absolutely, and that is the gestalt. We have got to. But does the system give us time to practice that good sort of medicine? Anonymous. It is getting harder, and with fewer and fewer of you out there doing this for more and more patients, it is getting really, really hard.
Right. There you go, Jess.
Jess:
Thank you so much, Geoff. Lots of comments coming through there saying it was a great presentation, so I really appreciate it. Just a reminder to everyone to please complete the evaluation that will pop up in a moment when the webinar session closes. It does not take any more than a minute to complete. Certificates of attendance will become available on your CPD statements within the next week. But for any non-RACGP members who would like a certificate, please email us rural@racgp.org.au and we can organise that for you. And do not forget to tune into our next free monthly webinar. So it will be held on Thursday, the fourth of May, from 7:30 to 8:30 p.m. AST. And it is going to be on running a rural skin service, how to be safe and effective.
And on that note I am going to end the webinar for everyone. So you can head off and have a wonderful evening and a wonderful Easter. So thank you again, Geoff, and thank you to everyone for attending, and hope that you all have a great night.
Dr Geoff Couser:
Great thanks, all, it is been an absolute pleasure, and I love the work that my colleagues, that you all do in primary care. You are holding it all together under immense pressure and against the odds. So keep up the good work. It is bloody hard. I do not know if it is ever going to get better. Maybe the good old days. Maybe I am old, and I will say the good old days were when I was younger. But maybe these are the good old days. Who knows? But all the best to you.
Jess:
Thanks, Geoff.
Dr Geoff Couser:
Okay.
Jess:
Good bye all.
Dr Geoff Couser:
Bye.