“If we hadn’t started the hospitalist field 24 years ago, we would have had to invent it now,” says Robert M Wachter, MD, a professor and chair of the Department of Medicine at the University of California, San Francisco, and the person who coined the term “hospitalist” in 1996. Hospitalists have become leaders, not just within their departments, but within their institutions, based on expertise in caring for critically ill patients. This leadership role has been solidified—and complicated—by COVID-19.
Now, patients who delayed seeing providers will arrive at their physician’s office or the emergency department with more advanced disease than if they had accessed healthcare six months ago—thus frequently landing in the care of a hospitalist Therefore, the time is right to identify what has led to claims against hospitalists in the past, to elevate awareness of problematic system factors and cognitive biases that can contribute to adverse events and subsequent lawsuits.
A just-released study of claims against hospitalists calls out diagnostic error as a particular risk for hospitalists and their patients: 40 percent of claims in the study were diagnosis related, making these claims more common than any other type. Compounding the usual diagnostic challenges at this moment is that in some locations, for months, COVID-19 has dominated the diagnostic landscape—potentially skewing the assumptions of the healthcare providers who send patients to a hospitalist’s care.
For example, when patients arrive for evaluation, healthcare providers may assume that those with respiratory symptoms have COVID-19—but what if it’s a pulmonary embolism, influenza, CHF, or a simple pneumonia? Healthcare providers may also assume that patients without respiratory symptoms do not have COVID-19—but what if they had it six months ago, and are now arriving at the hospital with a cardiac issue that is a sequela of COVID-19, a feared possibility as we learn more about ongoing organ system damage from COVID.
The study addresses these circumstances and suggests a core risk mitigation recommendation to not rush the process of arriving at a differential diagnosis—a strategy that is always relevant, and essential during the COVID-19 pandemic. One key to a rigorous differential diagnosis process is maintaining an open mind as long as possible, not falling prey to the anchoring bias, “the tendency to stick with initial impressions even as new information becomes available.”
The study also suggests that, when forming the differential diagnosis, hospitalists devote extra attention to any symptoms suggestive of certain diagnoses which, although rare in the general population, turn up with surprising frequency in claims against hospitalists; these should be kept top of mind. Co-founder of the Society for Hospital Medicine (SHM) John Nelson, MD, MHM, has identified spinal epidural abscess (SEA) as one such condition:
It’s valuable to have a large database of hospitalist claims to see the issues that are most likely to lead to patients deciding to sue a hospitalist. Of the diagnoses found most often in this study, spinal epidural abscess is notable for being a less common affliction, but disproportionately likely to lead to a suit. Doctors should maintain a high index of suspicion for this condition, which is relatively easy to diagnose. The challenging part in arriving at the diagnosis is to ensure it is considered as part of the differential diagnosis.
Dr. Wachter says that he consistently advises hospitalists to keep “a low threshold of worry” about SEA, because once symptoms present, the patient’s condition can deteriorate quickly. The study’s case examples show step by step how SEA was mistaken for other maladies, but advice from Drs. Nelson and Wachter affirms one of the study’s key findings: The process of arriving at a differential diagnosis is not to be rushed, as success after this point often depends on success at this point.
Open-mindedness assists hospitalists now especially because COVID-19 itself, compounded by treatment delays for assorted non-COVID-19 conditions, may lead to a demographic shift in hospitalists’ patients: Patients could be, on average, younger than usual. This could change how patient complaints present, increasing diagnostic difficulties and risks to patients.
The risks stemming from adverse outcomes rise for hospitalists in that an overall younger patient base also means that adverse outcomes, if followed by lawsuits, could lead to more expensive indemnities: Malpractice settlements measure economic damages, and the earnings lost by a professional in their forties will, naturally, be higher than those of a retiree in their eighties.
“Hospitalists have become the leaders in patient safety and in system improvement,” says Dr. Wachter, in part because the specialty coalesced around the idea that hospitalists could both take care of patients and, as specialists in caring for the very sick, see how to make hospitals better. Dr. Wachter says that he is “very proud of the field, which clearly stepped up during the pandemic in the face of personal danger and rapidly swirling changes and crises.”
That said, most hospitalists do not have control over local system factors, much less over situational factors stemming from the pandemic itself—some of which are crushing. Cognitive factors in individual decision-making, and possibly in the decision making of colleagues and team members, is where the individual hospitalist has control or immediate influence. Maintaining what Dr. Nelson calls a “high index of suspicion” for certain problem diagnoses, and maintaining a high index of awareness during the process of arriving at a differential diagnosis, could pay off in positive results throughout the patient’s course of care—and protect hospitalists from malpractice lawsuits.
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