When the Doctor Didn’t Listen to the Patient: A True Story of Misdiagnosis Malpractice1
Our client Meagan Moran (not her real name) was in many ways a model patient. A bright, cheerful, sandy-haired woman in her mid-forties, Meagan had achieved a master’s degree in health administration and had run two busy doctor’s offices, even helping her orthopedic-surgeon boss write speeches and raise money for a nonprofit foundation. She left the workforce to have children but still managed her daily life with precision and attention to detail. She made lists and schedules for her daily life and for her husband and two children. She entered them in a neat, small script in pencil in a Day Timer notebook. When things were done, she put a check mark on the list.
And when she felt sick on a Wednesday just before Easter, Meagan made another list, dutifully recording all her symptoms with a mechanical pencil in her neat script on a sheet of lined notepaper. She first recorded her recent history: The prior weekend, she’d had what she assumed was a vaginal yeast infection and had treated it with an over-the-counter drug but was still very irritated in that area. Monday and Tuesday, she had some pain below her rib cage and an episode of dark urine. But what prompted her to sit down and record all this on a Wednesday just after lunchtime was what she felt at 11:30 AM that day: “sudden onrush of radiating pain lower back, both sides,” with “chills, weak neck down.” And just below a reminder to pick up her kids from school, she wrote, “Had vag strep once before. Am I contagious?”
Meagan went to her internist early in the afternoon of that same Wednesday. We know, from what she wrote and what she told her husband later that day, that she was puzzled and worried about the sudden stab of pain in her lower back. She had a strong, healthy back, and hadn’t bent or twisted or lifted anything that could explain this pain. Plus, she had what she thought was the yeast infection in her vagina, or was it vaginal strep?
The internist did a short examination and assured her that most likely she was experiencing the first pangs of the flu, even though it was April, well past flu season. He did a pelvic exam and concluded that the irregular red rash on her vulva came from a yeast infection. He wrote prescriptions for a flu medication and an antifungal drug for the vaginal infection. He advised Meagan to go home, stay in bed, get plenty of fluids, and take the medications for what he assumed were two unrelated problems.
Only she didn’t have two unrelated conditions, but just one: streptococcal bacteria in her vagina that was starting to invade the deep tissues and produce back pain. The Monday after her Wednesday appointment, after dutifully following the doctor’s advice for five days, and after speaking to his medical partner on the Sunday night, she returned to his office, so weak that her husband had to enlist a security guard with a wheelchair to take her from the car to the doctor’s suite in the medical building.
The internist couldn’t get a blood pressure. He called 911. She was taken to a nearby hospital. All her organs were overwhelmed by the poisons produced by the strep bug, and even though she received intensive treatment, she died the next day. The final diagnosis: streptococcal toxic-shock syndrome. She was forty-six years old. And so Meagan joined the swollen ranks of patients victimized by an overly optimistic medical diagnosis made without carefully listening to the patient.
Ordinary penicillin could have tamed the group A Streptococcus bug that killed Meagan. It is one of only two or three bacterial strains that never developed antibiotic resistance.
There was plenty that the internist left out in his hurry to make a diagnosis. He took no culture of her vaginal discharge, did not check her urine, which she had told him was a dark color, and did not draw any blood to see if her white count was elevated (a sign of bacterial infection, not the viral flu that he assumed). But most of all, he didn’t listen to the whole story she told him. Instead, he picked out the parts that fit his preconceived idea of flu.
No one was in the exam room but the internist and Meagan. So how can we know he ignored pieces of her story? Because after she died, her mother found the sheet of paper from her Filofax day planner on which, in her neat, small script, Meagan had listed her symptoms before going to see the doctor, including her prescient final thought: “Had vag strep once before. Am I contagious?” She had drawn an arrow in the margin pointing to that last question. Her husband had seen her writing this list on her way to the doctor’s office.
None of these items in her notes made it into the doctor’s record of the visit, which he tapped out on a laptop computer. Why not? Either he hadn’t heard what she said, or he hadn’t asked her the thorough questions, body system by body system, that would have teased out her full story.
In the lawsuit that our firm brought against the internist on behalf of Meagan’s two children and widower, the internist tried to blame her for his not hearing the full story on that spring afternoon in his office. If he was right, then this patient, a Phi Beta Kappa college graduate with a master’s degree in health administration, had written out her history and symptoms just before the examination, but then had deliberately withheld the information from him during the exam.
That seems unlikely.
And while we’ll never know exactly what words were exchanged during the appointment, I think we can easily reconstruct how the miscommunication occurred. Meagan’s symptoms and worries that she wrote to herself did not penetrate the doctor’s consciousness, because of a common logical error that afflicts all of us when we sort out reality: Out of the jumble of perceptions we take in, we seize on what fits the pattern our mind wants to find, and we discard the rest. Usually we go with what fits our experience and preconceptions. This is called confirmation bias.
Confirmation bias is not always a bad thing. Experience shapes wisdom, at least some of the time. But truly wise doctors know that a patient’s illness may not fit into their preconceptions, so they are open to new information from the patient. And their training warns them of the peril of discarding pieces of the patient’s story. Yet because the vast majority of the patients a primary-care doctor sees in any week will have something benign and self-limited, doctors have a natural tendency to assume that the next patient on the schedule also has something benign. And that bias is a threat to any patient like Meagan, who has a truly serious condition.
Doctors are taught to ask an open-ended question when they first encounter a patient, something like, “What brings you in today?” Just as important as the question is the listening that is supposed to come next as the patient relates their problem, in their own words, without interruption. But researchers who observe doctor-patient encounters report that the ideal is seldom met. One study of the University of Chicago’s hospital emergency room found that while most doctors started with an open-ended question, four out of five patients were interrupted before finishing their answer. The average time until interruption: twelve seconds.
Communication is especially important for primary-care doctors, the first to encounter a patient’s new problem. A now-classic study from Oregon published in the Journal of the American Medical Association in 1997 found that, comparing never-sued primary-care doctors with those who had at least two claims against them, the never-sued doctors spent more time with patients, used more humor, and used specific tactics to facilitate communication, such as asking patients’ opinions, checking understanding, and encouraging patients to talk. That doesn’t make them perfect, just more likely to hear the patient’s full story and thus steer toward a more accurate diagnosis.
When I took the deposition of the doctor who misdiagnosed Meagan’s vaginal infection, he was stiff, cold, and superior. He didn’t need to test what her vaginal infection was, he said, because he could tell by a glance. A test would have wasted time and money. Meagan’s handwritten note came up only indirectly in the interrogation. I asked him if it wasn’t true that she would read her symptoms from her notes in the doctor’s office, something her husband had seen on other occasions. He said, “I don’t specifically recall that.” He also said he couldn’t say if she was a “good historian,” because he had no way of corroborating if she had forgotten, overstated, or understated any of her pertinent history. He admitted, though, that she had “excellent comprehension” and was “a very nice person whom I enjoyed having as a patient.”
So how did this very nice person end up with a body bloated with fluids that her lungs couldn’t clear and her kidneys couldn’t process, which finally caused her heart to shut down? Her internist was not a “bad doctor.” He certainly didn’t fit the clichéd image of the malpracticing doctor addled by drug or alcohol addiction or old age. He just didn’t listen well and thought he could guess his way toward the correct diagnosis rather than use any of the diagnostic tests at his disposal.
1This is excerpted and adapted from Patrick Malone’s book, The Life You Save: Nine Steps to Finding the Best Medical Care — and Avoiding the Worst.
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