诊断范围——参加DEM12018后的一些想法

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This past weekend I participated in the Society to Improve Medical Diagnosis annual meeting.  I saw many old and new friends.  Going to a meeting often stimulates thinking.  Because we often talk about diagnostic errors,我们必须首先定义诊断。当我听谈话时,观察海报,并与同事们讨论了一个更广泛的概念。and if so,please send me the reference.

诊断有几个层次。病人来看初级保健医生,cardiologist,急诊医生或其他人(包括紧急护理,执业护士,and physician assistants) because they have significant chest pain triggers a search for a diagnosis.  Similarly,体重减轻20磅(加上或减去其他症状)的患者可能会触发对诊断的搜索。

But the situations I began to think about are rather different.  Let's outline 3 such examples:

  1. A patient has a sodium of 120 – the diagnostic question is why.  We first need to 必威体育understand the immediate cause of the hyponatremia,but then we often need to examine the underlying diagnosis.
  2. A patient with known COPD comes to see you for worsening dyspnea.  Sometimes we label that as COPD exacerbation – but what is the real diagnosis causing the exacerbation?
  3. A patient presents with a creatinine of 3 with a known recent creatinine of 1.2.  Often we make the "diagnosis" of AKI,但这不是一个诊断。导致肌酐增加的原因——我们应该仔细地通过诊断过程来找到原因。

我想知道我们是否可以通过观察这些情况来了解诊断错误(我确信您可以将许多常见情况添加到此列表中)。我们如何接近基本诊断说明了我们的诊断过程?

作为一名临床医师教育工作者,我经常和学生们在一起,interns and residents on such concerns.  Do you?  Do you even consider such situations as diagnostic dilemmas?

Comments (3)

I run across these problems all the time.Unfortunately diagnostic errors are part of a larger systemic problem.I believe that most caregivers are doing the best they can for their patients,but we are driven to try to diagnose and fix a problem too quickly because of problems with the payment system.

Take your example of a patient with a sodium of 120.这个病人可能有很多问题。I would love to be able to admit a patient to the hospital with a diagnosis of "they are sick and we will try to figure out why".

但保险公司不允许这样做。不要说政府可以做得更好,因为医疗保险也能做同样的事情。每个人都想知道“入学标准”。病人病了怎么办?

一切都归结为信任。There is no trust in the doctor anymore.一些不好的球员对大多数医生来说已经破坏了这个领域。But the pendulum has swung too far in the direction of the payers.现在,我必须通过电话向一个只有高中文凭的几乎不识字的人证明我的医疗决定是正确的,如果是这样,who has never seen the patient.

I am not sure what the solution will be.如果医生得到了合理的薪水而不是免费医疗,这“可能”会有所帮助。然而,now many doctors are hospital employees and on salary,but the system just churns on the same way.现在,FFS部门被要求支付我们一开始根本不需要的所有医院管理人员的费用。Doctors are pushed to bring in revenue but have also been given the jobs of data entry,订单输入,and billing.And there has been no tort reform so the people ultimately held responsible should something go wrong are still the doctors.

我认为是时候对医疗制度进行彻底改革了,医生们从管理人员和会计人员那里夺回了职业。If that requires making each patient pay out of pocket and then having them settle with their insurance companies themselves,就这样吧。人们需要回到医疗体系中承担一些个人责任,and in the world in general.

一段时间前我患上了健康恐慌症,被送往一个地区医疗中心,在那里我和妻子得到了极好的照顾和支持。

One of the many things I learned was staff at all levels of this medical center were paid a salary and every patient is assigned two doctors.这些医生必须同意一项治疗计划,阻止我们在医学上看到的一些奇怪的想法。

The result of this is high quality,low cost medical care with above average outcomes.

在当今世界,金钱确实推动了医学的发展,可悲的是,它把它撞到了地上。

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