Islon Woolf MD
Concierge Medicine and accuracy
Updated: Jun 28, 2020
Diagnosis and treatment is the foundation of medicine. Accuracy is vital. Your health depends on the correct diagnosis, and the correct treatment. Unfortunately, a lot of errors are made in medicine. The error rate for diagnosis, for instance, is estimated at 10-15%. The Institute of Medicine has approximated that the damage from all of these errors is responsible for 100,000 deaths every year in the US. These figures may be exaggerated; nonetheless, a fraction of these numbers is still too much.
The error rate for diagnosis is estimated at 10-15%.
Medical regulators and licensing bodies are aware of the errors in medicine. They have devoted study to understand them, and implemented policy to prevent them. This started in the 1990’s. Interns in hospitals were observed making critical errors endangering patient lives because they were sleep deprived and overworked. Subsequent enforcement of shift work, with manageable hours and manageable workloads, lead to a decline in errors. Currently, all physicians in the United States are required to complete a course in medical errors every two years - this is mandatory for license renewal. The goal of these courses is to make doctors aware of the sources of error.
Sources of medical error
There are, in deed, multiple sources of medical error; the following are some of the most common:
Physician burnout - A mental condition experienced by overworked physicians affecting their performance. Studies (here and here) show that physicians with burnout make significantly more medical errors. Over 50% of physicians report burnout, and it's even more prevalent in primary care.
Decision fatigue - Accurately diagnosing disease and making important medical decisions requires a tremendous amount of cognitive effort. Too many decisions lead to an inability to make more decisions. For example, at the end of a busy day primary care doctors: prescribe unnecessary antibiotics and opioids, forget to offer vaccines, mammograms, and colonoscopies, and neglect to wash their hands.
Premature closure - There is a tendency for doctors to anchor to a diagnosis. Once a diagnosis is made, they fail to continue considering reasonable alternatives. As an example, a patient who drinks a lot of alcohol develops pain above the belly button. The doctor diagnoses stomach ulcer and prescribes an acid medication. The pain does not respond to treatment so the doctor decides to order an endoscopy. However, he should have considered other diagnoses, such as pancreatitis - which is also caused by alcohol and presents similarly.
Obsolete medical knowledge - Accurate diagnosis and treatment rely on a solid knowledge base. However, medical knowledge grows at an exponential rate and becomes obsolete almost as fast as it is learned. The typical doctor has little time to update knowledge. Excessive stress and workloads leave very little time for much else but work. Most doctors become obsolete shortly after training is complete.
System errors - Errors are not always due to errors of an individual, but rather, due to the errors of a faulty system. Errors in the steps in between diagnosis and treatment. The result of poor commuication and lack of follow through. For example, a doctor orders a mammogram. A suspicious lesion is found and the report is faxed to the office. However, it does not make its way to the doctors desk. The patient, not hearing anything, assumes the results are negative.
There is a simple message here - overworked doctors, and an overworked system, lead to errors. Providing more attention to fewer cases improves accuracy in medicine.
Concierge Medicine and accuracy
The Concierge Model of practice provides the best opportunity to guarantee patients accuracy in medicine. With a practice limited to 300 patients, and two to four visits per day, I can address each source of error:
Physician burnout - My low volume of patients makes practice rewarding and enjoyable. A personal relationship with each one of my patients motivates me to solve their problems. I enjoy medicine more than the day I graduated.
Decision fatigue - A low volume of patients ensures a low volume of decisions. Each patient is approached with fresh eyes, like they are the first patient of the day.
Premature closure - It is an imperative of my practice to constantly reconsider diagnosis and treatment. I have ample time to contemplate each problem, I maintain contact feedback with my patients, and I keep an attitude of intellectual humility and flexibility.
Obsolete medical knowledge - I embrace the concept that medical knowledge becomes obsolete very quickly. Hence, a core principle of my practice is lifelong learning. I approach each problem like a medical student - learning it from scratch - an opportunity to learn, relearn, and unlearn. In fact, I spend approximately one third of my day engaged in this form of learning. To consolidate this learning, I share this knowledge with my patients in educational emails. To read more about lifelong learning and my learning style, click here.
System error - I have designed my practice to excel in continuity of care. Tests ordered are followed through, test results are retrieved, and test results are communicated to you. Treatments are executed, treatment outcomes are followed up, and treatments are modified and changed when necessary. This is accomplished effortlessly in my practice with several features and failsafes, including: direct access, user-friendly electronic medical records, closed-loop communication, automated reminders, automated drug interaction checkers, and overstaffing my practice. To read more about continuity of care in my practice, click here.
Providing more attention to fewer cases improves accuracy in medicine.