A test is a useful tool, but can lead to ‘premature’ diagnosis

What happened to Alex Halstead demonstrates that sometimes a quick diagnosis isn't always correct.
Alex Halstead’s appendicitis wasn’t diagnosed during an initial ER visit.

It was finals week in December 2009 and Alex Halstead, a 19-year-old undergraduate at the University of Georgia, was doing some late-night studying for an exam the next day when she felt a stinging pain in her lower right abdomen.

The pain was severe, and she was worried that she might have appendicitis.

By midnight, thanks to her roommate, Halstead was at the emergency room of Athens Regional Medical Center. The doctor on duty felt the problem was serious enough to admit her.

“At this point, I’m pretty much keeled over in pain,” recalls Halstead today.

After recording her vital signs and hooking up an IV of painkillers, the doctor gave Halstead what she remembers as a “metal-flavored milkshake.” This was a contrast agent that makes it possible to view abdominal structures –- such as a swollen and inflamed appendix –- using a CT scan.

The CT scan, surprisingly, showed nothing out of the ordinary.

Based on that scan, the doctor ruled out appendicitis. He concluded instead that Halstead had an ovarian cyst, a much less threatening condition. She’d had one before, and women in her family were plagued by endometriosis, which can sometimes cause intense abdominal pain.

As it turned out, the doctor was wrong.

Looking back, the emergency room doctor appears to have made a type of medical error known as “premature closure,” said family practice expert Mark Ebell, a member of the U.S. Preventive Services Task Force and a professor in UGA’s College of Public Health. This type of mistake happens when a doctor reviews the patient’s symptoms and makes an initial diagnosis without adequately considering other possibilities.

In this case, the doctor jumped to a conclusion based on Halstead’s medical history and the CT scan results.

The doctor at Athens Regional sent Halstead home with pain medication and recommended that she contact her gynecologist in the morning. Her alarmed mother rushed to Athens that morning and drove her to the office of gynecologist Frank Lake, who practices in Gainesville at Northeast Georgia Physicians Group, which is affiliated with Northeast Georgia Medical Center (NGMC).

When Halstead described her symptoms to Lake, he said it sounded like “textbook appendicitis.” He didn’t put much stock in the CT scan, because such tests inevitably miss a certain percentage of appendicitis cases.

“The mistake that can be made is that we rely too much on our diagnostics,” said Lake.

Lake immediately called a colleague at NGMC for a surgical consultation. When Halstead arrived at the hospital, it didn’t take long for the surgeon to identify the cause of her pain.

[youtube]http://www.youtube.com/watch?v=klNODrTQxr0[/youtube]“He hit the bottom of my heel, and I started immediately vomiting and crying,” Halstead remembers. What she had was appendicitis, just as she had initially feared, and she was rushed into surgery.

Even a slight jolt can cause someone with acute appendicitis to vomit. Knowing that, the surgeon had used a simple physical maneuver –- not fancy equipment –- to identify a potentially life-threatening problem.

In this instance, one doctor’s educated guess and another’s basic exam technique yielded a better diagnosis than did a complex test. But in fairness, Lake readily acknowledges that he and the surgeon may have benefited from the passage of time in Halstead’s case. When they saw the young student, her condition was surely much worse and more obvious than when she was examined in the emergency room.

Thinking is a subtle thing

Many hospitals now use checklists and other protocols to prevent “procedural” errors, the kinds of mix-ups that can potentially cause a patient to get the wrong medicine or the wrong surgery. But systematic efforts to reduce errors in judgment –- such as misdiagnosing Halstead’s appendicitis –- have lagged behind, said Dr. Scott Richardson, campus associate dean for curriculum at the GRU-UGA Medical Partnership in Athens.

Diagnosis happens in the mind of the physician, not in a public, documented setting. This complicates the challenge of developing regulations or policies that prevent errors. But Richardson sees two areas that policy shifts can target.

The first is noise.

Emergency rooms and intensive care units are often noisy places, making it difficult for doctors to detect subtle clinical symptoms. For example, a quiet but dangerous heart murmur can be drowned out by the cacophonous environment of the ER.

Last November, CBS News reported that a hospital in the Canadian province of Ontario tackled noise pollution by installing sound-absorbing ceiling tiles, creating more private rooms and moving overhead loudspeakers to the hallways instead of over patients’ beds.

Richardson also believes the reimbursement system needs an overhaul.

Sometimes a doctor cannot make an accurate diagnosis after the first meeting with a patient. But under the current system, doctors can be reimbursed only for time and procedures linked to a specific billing code, which reflects a diagnosis. This puts pressure on physicians to label a condition before they really know what it is, Richardson said.

“Some label has to be applied,” said Richardson. “That label develops a kind of momentum, a life of its own, and that tends to narrow further thought.”

In the same way, relying solely on imperfect technology, as the initial doctor did in Halstead’s case, can prevent physicians from using their clinical skills and common sense to figure out what’s troubling their patients.

“If it walks like a duck, and it quacks like a duck, it’s probably a duck,” said Lake.

Nearly 7 percent of people are afflicted with appendicitis at some point in their lives, and the ailment is misdiagnosed between 20 percent and 40 percent of the time, according to the Agency for Healthcare Research and Quality.

Ian Branam is a second-year master’s student in health and medical journalism at the University of Georgia. He is interested in developing health and medical content for the web and spent the summer developing a social media campaign for smoke-free workplaces. He particularly enjoys writing about health policy, health disparities and chronic diseases. Follow him on twitter at @ianbranam or visit his website at www.ianbranam.com.