Misdiagnosis is a common type of medical malpractice, but not all misdiagnoses are the result of negligence. To constitute malpractice, the misdiagnosis must result from underassessment, under-testing or misinterpretation of test results that falls below acceptable standards of medical care. I was thinking about misdiagnosis cases as I read the obituary of Lawrence Weed, M.D., a physician who tried to improve patient safety by developing a standard assessment and charting practice that all physicians are supposed to follow.
All physicians are trained to use the ‘differential method’ to reach a diagnosis. The differential method requires the physician to collect information in order to create a list of potential diagnoses. Then the physician needs to test for and rule out the most likely diagnoses, and also those diagnoses that are life-threatening. For instance, when a patient presents with burning chest pain, they may simply have heartburn. In fact, heartburn is probably the most likely diagnosis, particularly if the patient has a history of heartburn or has recently eaten spicy food. But it would be negligence to conclude that the patient has heartburn without further testing and evaluation. Why? Because burning chest pain can also be a sign of a heart attack. So, a careful physician will draw blood to test for a rise in the enzyme troponin, which is evidence of a heart attack.
To organize doctors’ efforts to work-up a proper diagnosis, Dr. Weed came up with the so-called “SOAP note.” SOAP stands for Subjective, Objective, Assessment and Plan. The Subjective part of the note deals with the patient’s chief complaint and related details, such as the patient’s past medical history, and the type, duration, character and onset of symptoms. The Objective part of the SOAP note refers to objective findings such as the patient’s age, weight, vital signs, the patient’s appearance, physical assessment and test results.
The Assessment should contain a list of potential diagnoses that are based on the subjective and objective findings. The final portion of the SOAP note is the Plan. This should reflect any tests that the physician must conduct to rule out incorrect diagnoses and thereby narrow the list of possible diagnoses, as well as the treatment plan (e.g., medication, surgery, etc.).
In my experience, doctors in training, i.e., internists and residents, write their SOAP notes carefully, paying attention to important details. They do this because they are being evaluated by attending physicians to determine whether they can implement the differential diagnosis process and record all information that is pertinent to the diagnosis. Indeed, attending physicians who are ultimately responsible for patient care are required to sign off on residents’ SOAP notes to reflect that they agree with the residents’ process and findings.
Unfortunately, many physicians deviate from the SOAP note and the differential diagnosis process when they become attending physicians. Rather than being thorough and applying Dr. Weed’s formatted analysis, they rely on experience and judgment. Experience and judgment are important and necessary, but they are no substitute for safety and thoroughness. As a medical negligence lawyer, I have seen firsthand how cutting corners can have catastrophic consequences.
One example of such negligent corner cutting occurs when a younger patient suffers from an illness that is usually associated with older patients. We have seen in recent years a rise in the incidence of stroke, heart attack, breast cancer and malignant melanoma occurring in younger patients. If a physician encounters such a patient and concludes “you’re young, it’s probably nothing,” that would be the right conclusion based on their experience and judgment. However, by failing to implement the differential process and failing to rule out serious life-threatening disease through proper assessment and testing, the physician puts the patient at an unnecessary risk of a bad outcome. If harm results from the misdiagnosis, then a claim for medical malpractice may be brought under Ohio law.
Rest in peace, Dr. Weed. And thank you for your efforts to improve patient safety.
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