Ep 19: Getting the diagnosis wrong!

Hey everybody, it's Alex here from Clinical Practice Made Easy. Today I'm going to talk about a bit of a tricky topic for practitioners which is what do we do when we've got the diagnosis wrong and I know that this is a really big fear and I actually don't think it really matters whether you're newly qualified or experienced. We are testing our patients, we're taking a really thorough history, we're starting care with a diagnosis in mind and then we discover it isn't what we thought it was. And that may be that the patient wasn't responding to care or that they had images and it showed up something else or that they ended up seeing somebody else and they had a differing opinion and it may have come to light that they were right. And these situations are always really tricky and I'm not necessarily talking about situations where we discover it's a red flag, I think that's different. What I'm talking about is when it's something that's still in our remit. So it's a condition that we can still take care of when we are aware of the new diagnosis when things have come to light. Now I think that there are some real challenges here because one is we're kind of worried about not being good enough and really not demonstrating that we've supported the patient or losing their trust. I think there's a worry about that. I think there's worry about not being sure how to communicate it now. It's been discovered and is it that we found it ourselves? I'm going to actually I'm not sure that this is what I thought it was in the beginning or is it that somebody's now presented us with new information that we haven't found and it's really awkward because we think I'll know how am I going to kind of bring this back so that the patient still trust that I can help them with this. And then we've got to start a new plan, measure and follow that up and we also need to make sure that the patient understands it. They're on board with it and that they are happy with our next step. So it's pretty complicated and there are a few things that I see that are mistakes I would say and the most common one is probably the practitioner becoming quite defensive and that may be either not agreeing with the information that the patient's provided or not really wanting to be wrong. And let's be honest, how often do we want to be wrong about something? Because I certainly don't. So I think that those two things defensiveness are not wanting to be wrong are actually about us as practitioners. Now I know not all of you will respond in that way but I do see such that quite commonly and I've taught you guys before about biases. We'll try and find information to support ourselves because really what we don't want to accept is that we've made a mistake because we think the consequences of that are that we are going to lose something in some way. Now the challenge with that response is it doesn't actually help the patient at all. That's our own issue. I would normally say take that out of the room, talk to your coach or mentor about that and spend some time protesting on it. You know, accept that that's how you're feeling but put it aside because that's not what needs to happen in the patient's space. So I think if I can give you a few steps of guidance there are probably four things I'm sure there's more that you can do but I think the first thing is is not taking it personally. So what I usually do and trust me, you know, I'm still in practice now and I'll get new information or somebody who provides me with something that changes what I think is happening. But what I do is do two things. One is I accept it as new information. It's just logical. They've provided me with something new and I'm like, wow, that's really interesting. Let's have a look. Oh, we weren't expecting this where we and that's really interesting language because that keeps us in alignment. And we weren't and it's true, right? We weren't expecting it, otherwise we wouldn't be looking after them in the way that we were looking after them. Second thing is, so I'm not going to take it personally. I'm going to be like great new information. Let's see what we do now with it. Second thing is it's a working diagnosis. So it is normal when we diagnose a patient to do it with the base of the best set of facts that we have at that possible time. Now sometimes we're going to get more information as we go and one of the big factors I always talk about is time is more information. It's not always images. It's not always tests. It's sometimes it's just time that gives us more information. So if we accept that this is a working diagnosis, then we give ourselves a little bit of slack and every healthcare practitioner is working with a working diagnosis. And one of the things that we have to remember, even with imaging, imaging isn't always functional. A lot of the time imaging is a photograph. It doesn't tell us about movement. It just tells us about structure. So even that doesn't always give us the full picture of what's happening or what's causing a patient symptoms. So I think that first thing is don't take it personally. It's just new information and the language that I would use with that patient is, while we weren't expecting that, where we let's have a look at this together and come up with a plan. The second thing is, is own it. So what I mean by that is, it's not, oh, I didn't do this or I didn't know or, you know, justifying ourselves. You know, we've said to the patient, we weren't expecting that. Let's come up with a plan. I'm just going to start reassessing. I mean, like, okay, based on this information you've given me, you're not responding or that image or the person that you saw, let's do some extra tests because that wasn't the response I was expecting. That wasn't the outcome I was expecting. That wasn't the information I was expecting. And that's true. So let's have a look at it. And now what we can do, and it might be that you send information, now that we can do is we can work on this together. One of the mistakes that I also see in this situation is that sometimes healthcare professionals can get into competition with each other. So one type of healthcare professional said it's one thing and we think it's something else. I always think it's really important to do a couple of things here. One is to stay in alignment. I think it's really disrespectful and it doesn't put us in a good light to say something negative about what somebody else has said. So if I'm not sure I agree with it, I would say to the patient, what's your view on this information? How do you feel about it? And if they say, well, actually, I'd like to try this or I'd like to do that and I go, yes, and great, who's going to look after you for this part because they can do this and I can do this. Or yes, let's do that and we can do this together. Now sometimes what I will hear as people will say, well, I've been told by another practitioner not to see you while I'm doing this. And in my practice, I would never tell a patient not to see another practitioner. I think it's their choice, what they do. And we can often manage it. And we do a lot of co-managing and I'll practice and do a lot of respect for other healthcare professionals. So if that comes up, my first question to the patient is, how do you feel about doing it that way? Because I really want to know what they think. I'm not going to just go into, don't do that and don't do this. I want to know how they feel. And a lot of the time the patient will say, well, actually, I'd rather carry on with you and do that as well. And I'd be like, okay, great, let's do that. If they say, I want to try that and then do this after, then I would say, okay, so we're going to pause it for this period of time and then we're going to check you at this period of time. But I would say just make sure they're going to be looking after this. I'm going to be looking after this. So we want to make sure that this second part is not going backwards while this first part has been looked after. And a lot of the time it's true. Most of the time it's true, hopefully all of the time. So the next part is we're just not difficult person. It's new information. We're owning it. We're staying in alignment with the information that they've given us. And we're asking them how they feel about it. And we're reassessing them and we're taking that information on. We're digesting it. And then what we're going to do is we're going to come up with a plan. And this is what we're going to do now. And it might be that we trial some extra techniques, a new approach. It may be that we retest. It may be that we send further testing. It may be that we no longer look after that body part while something's being done and we look after the rest of the person. It doesn't have to be complete referral out always. But we would agree it. And then we would follow it up. And I think this process is so important because patients often feel like they have been kind of left floating in the wind. They haven't been anchored and supported and follow up and checked. And I think that the quality of being a good practitioner is to make sure that you are always following up and being really consistent in that way because that's what makes us reliable and trustworthy. The last thing is that you can actually be proactive. There are certain conditions in practice that will usually have a differential. So for example, the things that I see most commonly misdiagnosed are a rotator cuff or an impingement syndrome that actually was a frozen shoulder. And I think there's science behind that. So let's say somebody's got micro trauma to some of their shoulder muscle tendons, they develop a tendonitis, the body starting to heal in repair, it's laying down your tissue, that tissue gets attached to the shoulder capsule, it then develops into a frozen shoulder, so it started off as a rotator cuff and now it's a frozen shoulder. That for me is not a misdiagnosis, that's just not me ricking clear to the patient what the possibilities are, if we look after it or we don't look after it in a certain way and sometimes that process is already beginning, we can't run it, so if we've been proactive, when we see a rotator cuff or an impingement issue, we are going to have that conversation about potentially this may be a frozen shoulder but we don't know yet because it could be in the early stages. The same thing is with lower back problems or pelvic problems and discs, you know if the patient's had a history of a leg symptom let's say but they've presented with a lower back problem now with no leg symptoms, there is a possibility because they've had it in the past that they may have a pro-drone or disc, and so I'm going to talk to my patient about that, I'm going to say to them look my diagnosis at this point is that there's irritation around the nerves of these joints and that's causing you pain, however sometimes in the early stages of the lower back problem there can be changes to the disc as well and that disc material can start to press on the nerve too and it's the same nerve so it's the same symptom but if this disc process develops then you will start to experience this and this, now one of the best things about having that conversation is now a patient does experience that and they're saying yes you were right and we're going yes we know that that potentially was was a risk but while I would say to that patient is I'm going to look after you like this is a disc problem so now I know I'm reducing the chances that there've been child complications due to care so I think those little things are those proceeding conversations that will make a really big difference to us having a situation where we've got the diagnosis wrong because we're giving our patients the differentials we're telling about that in advance and then when you get the MRI result back and says it's the disc you but go well we knew it was a possibility there isn't a trust issue there isn't a communication issue you don't have to have a conversation about what the plan is is because you discussed it in advance so I hope that you found that useful key things are don't take it personally it's just new information is that it's only a work in diagnosis and something's just come up with time number two is own it you know reassess if the information has come from somebody else stay in alignment be trustworthy and and be honest about what you can help them with and what other practitioners can help them with and then make sure you've got a plan that you've tried and tested it and that you've followed up so that you're being consistent reliable and supportive and honoring the agreement that you made all of these things need to be in really strong 50-50 communication with the patient because it's their body and their care and then be proactive if something can potentially have a differential talk about it because then you're not in a situation where you've got the diagnosis wrong you've you're just in a situation where something's developed over time and now you've got a new information so I hope you found that podcast useful if you've got any questions you can always send me an email Alex at wellbeingrev.com sign up to our weekly guide to success because we talk about things like this and the link is in the bottom of the post and if you need anything else I'm always here.