1. Every Patient Tells a Story Lisa Sanders M.D.

2. Diagnosis: Mysterious Psychosis

5. 70-90% of diagnoses are made based on the patient’s history alone.

6. Diagnostic Triad Patient Diagnosis Doctor Story

7. Diagnostic Triad Patient Diagnosis Doctor Story

8. Diagnostic Triad Patient Diagnosis Doctor Story

9. 5 doctors in 5 different practices in urban and rural England 80 patients without a diagnosis Each doctor recorded their differential diagnosis after each step of the evaluation: history, physical, test results Hampton, BMJ 1975

10. Correct diagnosis made after: History 68% (66/80) Physical exam 9% (7/80) Testing 9% (7/80) Hampton, BMJ 1975

11. 4 physicians in practice is Utah 80 patients without a diagnosis Each doctor recorded their differential diagnosis after each step of the evaluation: history, physical, test results Peterson BMJ 1992

12. Correct diagnosis made after History 76% (61/80 ) Physical exam 12% (10/80) Testing 11% (9/80) Peterson BMJ 1992

13. Patients spoke for an average of 23 seconds before the physician interrupted them with a question Some physicians waited only 3 seconds before interrupting the patient

14. Doctors were more likely to interrupt if the patient was a woman than if it was a man Male doctors were more likely to interrupt than their female counterparts

15. 2% of patients resume their story after being interrupted. When interviewed after a doctor patient encounter, doctors and patients did not agree on what the encounter was about Most patients had problems they didn’t get to address

16. Time pressure Why doctors miss the story:

17. The average in-office doctor visit lasts 16-22 minutes

18. Most stories last 60 seconds and none lasted longer than 150 seconds - 2.5 minutes

19. Visits where doctors did not interrupt lasted on average 1 minute longer

20. Krista’s Story

21. Lemierre’s Syndrome External Jugular vein

22. Why doctors miss the story: Lack of training

23. Why doctors miss the story: Discomfort with patient emotions

24. Dan’s Story

26. 55% of patients surveyed said that their greatest concern after seeing a doctor was a misdiagnosis

27. Up to 15% of diagnoses made in primary care specialties will be wrong

28. “An estimated 40,000-80,000 hospital deaths result from misdiagnoses annually.” Newman-Toker, JAMA, 2009

29. Ask your doctor: “What else could this be if it’s not that?”

30. Tell your story - even after you’re interrupted

31. Diagnostic Triad Patient Diagnosis Doctor Story

32. Between 2-3% of patient leave the hospital AMA (Against Medical Advice)

33. 25-50% of patients do not take their medications as prescribed

34. Andy’s Story

35. Andy: Linds, something's wrong Lindsay: what do you mean? Andy: my memory is all f'ed up Lindsay: what is wrong? Lindsay: call the DOCTOR NOW! tell them it is an emergency. Lindsay: How is it all f'ed up? Andy: short term, i can't remember anything

36. Limbic Encephalitis

37. Diagnostic Triad Patient Diagnosis Doctor Story

38. Thank you