Health and Psychology

This question was raised at the Health Psychology group I belong to.  The situations were a bit different but the questions remained. 

• "I referred a patient out for a dementia work up and they said he was normal." 

• "I referred a head trauma patient out for an evaluation and the test came back anxious, not head injured."

• "I referred a patient out for a medical evaluation.  They said the symptoms were all in her head, not real."

Several of us.  We're in our 50's and 60's.  In clinical practice for 30 to 40 years.  So we see things differently.  What we see is clinical medicine.  It's based on experience and nuance.  So when we send someone out for an evaluation we expect the same kind of evaluation we have already done.  We're expecting confirmation of our clinical experience.

• The dementia case was diagnosed as dementia.  It took 3 years.
• The head trauma case was diagnosed with a brain injury.  It took 4 months.
• The patient had end stage cancer by the time she was diagnosed.  She died a year later.

And we feel guilty, because we knew.  We knew.  We knew.

So what do we do to improve things?  We teach.  We mentor.  We supervise. 

Some of the problems are the tests.  We were trained on old tests designed to help localize problems to the cortex.  The Halsted-Reitan Neuropsychological Test Battery, The Luria Nebraska Neuropsychological Test Battery, The Boston Neuropsychological Test Battery.  Younger neuropsychologists are less likely to use the old measures calling them "out of date," "old fashioned," or "archaic."  The Luria Nebraska isn't even being sold any more.  Neither are parts of the Boston Neuropsychological Battery.  They aren't profitable.  Too few people are trained on their use.  They are expensive.

Pathognomic findings.  The signs and symptoms of disease that lends to diagnosis.  We know these. 

• Lower than expected speech, language and memory given occupation and educational history.
• Signs of bilateral injury to the brain with sensorimotor impairment, executive dysfunction and occipital impairment suggestive of impact to the skull with blunt force.
• Chronic pain, fatigue, abdominal bloating, weight loss.  Excess caffiene use not stopping the fatigue.

So we refer.  The patient gets a brief consultation.  A minimal review.  A standard evaluation.  And the pathognomic symptoms get missed. 

So I write consultations and talk to the patients and I'll go to their appointments with them if I have to and they want me to.  And after all that if things still get missed then at least I know I've done what I could. 

In talking with my colleagues yesterday I found out we're all doing this.  And we're all doing it for the same reason.  Because just missing one case, one diagnosis, is one case too many.