At the end of this activity, you will be able to:
- Recognize how a lack of communication among providers can disrupt the continuum of care and lead to frustration for patients.
- Summarize how clinician bias can influence a diagnosis and affect a patient’s care experience.
- Discuss how unnecessary tests and incorrect diagnoses can add significant costs to the health care system.
In a new patient story, you’ll hear from Rani, a patient who visits several different health care providers in search of a diagnosis. As you follow Rani’s story, you’ll be prompted to stop along the way to consider a number of questions about miscommunication, cost, and the patient perspective. When you get to the end of the story, you’ll hear from Rani as she looks back on the experience seven years later.
Rani is a healthy and fit 45-year-old mother of two boys, ages six and four. She leads an active lifestyle as a parent – often twisting and maneuvering strollers, groceries, and her children around her hilly neighborhood in Berkeley, California. Rani also works part-time as an epidemiologist conducting health services research.
Since her early 40s, Rani has experienced increasing discomfort in her hip and along her leg during physical activities, but had written off the pain as a result of the physical demands of having two young children. By age 45, however, the discomfort has turned into something she can’t handle. Whenever one of her children runs into her legs, pain shoots up into her right hip. Her gait alters, and she experiences strong discomfort when walking, jogging, carrying her children, or sitting for long periods of time. The pain often wakes Rani in the middle of the night.
She cannot think of any recent or past accidents that would account for the increase in pain that she’s experiencing.
As her pain and associated difficulties reach an all-time high, she schedules a visit with her primary care physician (PCP) to find out what is going on. After hearing about the pain in Rani’s hip, the PCP asks a few questions, manipulates various parts of her torso and legs, and concludes that she most likely has a degenerative problem in her lower back. Rani responds that she feels pain in her hip, not her lower back, and that she has never had any lower back problems.
The PCP orders lower back x-rays of Rani’s spinal column, but is unable to come up with a diagnosis based on the x-ray results. She refers her to a physical therapist and adds, "Everyone has lower back problems. My whole family has lower back pain. Just live with it."
Discussion Question: What do you think of the clinician’s diagnosis? Can biases – similar situations or cases that have gone wrong –influence a diagnosis? How?
Rani returns home with no relief for her pain. She visits a physical therapist and has difficulty pinpointing an exact location for her pain. Together, they commit to 10 sessions of stretches, exercises, and other forms of therapy to treat her unknown condition.
Early during the course of treatment, the therapist concludes that stabilizing Rani’s right knee appears to give her the most relief from her pain. Rani returns to her PCP with this information; she receives knee x-rays that reveal no abnormalities or possible other causes for her pain. At the end of 10 weeks, Rani’s physical therapy ends with only minor relief from the pain in her hip.
Rani’s PCP is not sure where to direct Rani for further care. After a quick discussion, they decide to send Rani to a rehabilitation medicine specialist, otherwise known as a physiatrist, to seek a diagnosis. The visit occurs in June, six months after the acute pain began. At their first session, the physiatrist conducts more manipulative tests on Rani’s body and orders an x-ray of her right hip. He receives a copy of the report – and not the x-ray film – and is unable to come up with a definitive diagnosis. He subsequently orders an MRI of Rani’s right hip to further investigate the cause of her pain. When the results come back, the physiatrist is unable to comprehend them or make a definitive diagnosis. Rani leaves – now eight months into her pain – without recommendations for further treatment.
Discussion Question: Put yourself in the patient’s shoes. It’s been years since you’ve started on your journey with this pain. And it’s been too much to bear for eight months. You can’t sleep very well at night and daily activities that were once easy are now a great challenge. Discuss what emotions you would be feeling.
Rani’s husband, a professor of Health Policy and Epidemiology, suggests that she visit one of his orthopedist colleagues who specializes in hips. The orthopedist reviews Rani’s MRI and hip x-ray report, and explains that she most likely has arthritis in one or both hips.
Rani requests a referral from her PCP and visits an orthopedist in her network. He confirms the suspected diagnosis of arthritis. During her visit, the orthopedist listens to her description of her pain as he reviews the report from her right hip x-ray, the images from her MRI, and her MRI report. He laughs and says that the only thing the MRI shows is that Rani had the fullest bladder he’s ever seen on an MRI. He apologizes for Rani’s delay in diagnosis and the lack of straightforward service that she received during the past nine months.
Discussion Question: Compare Rani’s visit with her orthopedist and her initial visit with her PCP. What is different?
The orthopedist goes on to explain that he needs to examine both of Rani’s hips so that he knows what is normal for her body and requests a bilateral x-ray, which will capture an image of both hips. The x-rays are performed during this office visit.
Discussion Question: This is the fourth set of x-rays Rani has had for the pain. She also had the three referrals and an MRI, which didn’t help diagnose the injury. Think about the cost to the health care system. How could it have been avoided?
Together, Rani and her orthopedist discuss medication possibilities, changes in exercise routine, and other lifestyle changes she may make in order to improve her condition. The pain isn’t completely gone, but it returns to a low level that allows Rani to sleep better, exercise more, and keep up with her children.
Now take a few moments to listen to Rani, as she tells us about the lasting effects of her experience, including how she feels seven years later, what she would have done differently, and how health care providers can learn from her story.
- How does hearing from the patient affect your feelings about this story?
- How can we prevent Rani’s experience from happening with another patient?