Times article, doctors get it wrong

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Here's the text of a Times select article about our favorite

profession.

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February 22, 2006

Why Doctors So Often Get It Wrong

By DAVID LEONHARDT

ATLANTA

ON a weekend day a few years ago, the parents of a 4-year-old

boy from rural Georgia brought him to a children's hospital here

in north Atlanta. The family had already been through a lot. Their

son had been sick for months, with fevers that just would not go

away.

The doctors on weekend duty ordered blood tests, which

showed that the boy had leukemia. There were a few things

about his condition that didn't add up, like the light brown spots

on the skin, but the doctors still scheduled a strong course of

chemotherapy to start on Monday afternoon. Time, after all, was

their enemy.

Bergsagel, a soft-spoken senior oncologist, remembers

arriving at the hospital on Monday morning and having a pile of

other cases to get through. He was also bothered by the skin

spots, but he agreed that the blood test was clear enough. The

boy had leukemia.

" Once you start down one of these clinical pathways, " Dr.

Bergsagel said, " it's very hard to step off. "

What the doctors didn't know was that the boy had a rare form of

the disease that chemotherapy does not cure. It makes the

symptoms go away for a month or so, but then they return. Worst

of all, each round of chemotherapy would bring a serious risk of

death, since he was already so weak.

With all the tools available to modern medicine Ñ the blood

tests and M.R.I.'s and endoscopes Ñ you might think that

misdiagnosis has become a rare thing. But you would be wrong.

Studies of autopsies have shown that doctors seriously

misdiagnose fatal illnesses about 20 percent of the time. So

millions of patients are being treated for the wrong disease.

As shocking as that is, the more astonishing fact may be that the

rate has not really changed since the 1930's. " No improvement! "

was how an article in the normally exclamation-free Journal of

the American Medical Association summarized the situation.

This is the richest country in the world Ñ one where one-seventh

of the economy is devoted to health care Ñ and yet

misdiagnosis is killing thousands of Americans every year.

How can this be happening? And how is it not a source of

national outrage?

A BIG part of the answer is that all of the other medical progress

we have made has distracted us from the misdiagnosis crisis.

Any number of diseases that were death sentences just 50

years ago Ñ like childhood leukemia Ñ are often manageable

today, thanks to good work done by people like Dr. Bergsagel.

The brightly painted pediatric clinic where he practices is a pretty

inspiring place on most days, because it's just a detour on the

way toward a long, healthy life for four out of five leukemia

patients who come here.

But we still could be doing a lot better. Under the current medical

system, doctors, nurses, lab technicians and hospital executives

are not actually paid to come up with the right diagnosis. They

are paid to perform tests and to do surgery and to dispense

drugs.

There is no bonus for curing someone and no penalty for failing,

except when the mistakes rise to the level of malpractice. So

even though doctors can have the best intentions, they have little

economic incentive to spend time double-checking their

instincts, and hospitals have little incentive to give them the tools

to do so.

" You get what you pay for, " Mark B. McClellan, who runs Medicare

and Medicaid, told me. " And we ought to be paying for better

quality. "

There are some bits of good news here. Dr. McClellan has set

up small pay-for-performance programs in Medicare, and a few

insurers are also experimenting. But it isn't nearly a big enough

push. We just are not using the power of incentives to save lives.

For a politician looking to make the often-bloodless debate over

health care come alive, this is a huge opportunity.

ph Britto, a former intensive-care doctor, likes to compare

medicine's attitude toward mistakes with the airline industry's. At

the insistence of pilots, who have the ultimate incentive not to

mess up, airlines have studied their errors and nearly eliminated

crashes.

" Unlike pilots, " Dr. Britto said, " doctors don't go down with their

planes. "

Dr. Britto was working at a London hospital in 1999 when

doctors diagnosed chicken pox in a little girl named Isabel

Maude. Only when her organs began shutting down did her

doctors realize that she had a potentially fatal flesh-eating virus.

Isabel's father, , was so shaken by the experience that he

quit his finance job and founded a company Ñ named after his

daughter, who is a healthy 10-year-old today Ñ to fight

misdiagnosis.

The company sells software that allows doctors to type in a

patient's symptoms and, in response, spits out a list of possible

causes. It does not replace doctors, but makes sure they can

consider some unobvious possibilities that they may not have

seen since medical school. Dr. Britto is a top executive.

Not long after the founding of Isabel Healthcare, Dr. Bergsagel in

Atlanta stumbled across an article about it and asked to be one

of the beta testers. So on that Monday morning, when he couldn't

get the inconsistencies in the boy's case out of his mind, he sat

down at a computer in a little white room, behind a nurse's

station, and entered the symptoms.

Near the top of Isabel's list was a rare form of leukemia that Dr.

Bergsagel had never seen before Ñ and that often causes

brown skin spots. " It was very much a Eureka moment, " he said.

There is no happy ending to the story, because this leukemia

has much longer odds than more common kinds. But the boy

was spared the misery of pointless chemotherapy and was

instead given the only chance he had, a bone marrow transplant.

He lived another year and a half.

Today, Dr. Bergsagel uses Isabel a few times a month. The

company continues to give him free access. But his colleagues

at Children's Healthcare of Atlanta can't use it. The hospital has

not bought the service, which costs $80,000 a year for a typical

hospital (and $750 for an individual doctor).

Clearly, misdiagnosis costs far more than that. But in the current

health care system, hospitals have no way to recoup money they

spend on programs like Isabel.

We patients, on the other hand, foot the bill for all those wasted

procedures and pointless drugs. So we keep getting them. Does

that make any sense?

(end of article)

Didn't I read someone else's using the phrase " as if we hadn't

had enough " ?

[Guest guest]

See response below.

alblau999 <alblau999@...> wrote:.

Why Doctors So Often Get It Wrong

By DAVID LEONHARDT

But we still could be doing a lot better. Under the current medical system,

doctors, nurses, lab technicians and hospital executives are not actually paid

to come up with the right diagnosis. They are paid to perform tests and to do

surgery and to dispense drugs.

And that is the bottom line $$$$$$$$.