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Would you rather misdiagnose or misdispose?

February 22, 2013

Over the past two weeks I have been completing a rotation focusing on the administrative aspects of the emergency department. Halfway through a shift with one of my admin mentors, the quality improvement ninja and philosopher king known to most as Dr. Mark Wahba, we played a brief game of “Would you rather?”

If you have yet to be initiated, you probably need to get out more. “Would you rather?” is a party game played by the immature at heart that forces you to choose between two (generally) less than desirable options. It has spawned its own wikipedia page, three large websites filled with often inappropriate (you’ve been warned!) questions (here here here), a television game show and a B-list horror movie.

In this case, the dilemma was more serious and involved two desirable options, but I found it no less difficult. The question:

Would you rather get the correct disposition? Or the correct diagnosis?

Before you say both, remember that you can’t. I don’t care if you’re that good, that’s not how the game works – choose one!

To me, the answer seemed intuitively obvious at first. Disposition, of course! Who cares if we don’t get the right diagnosis if we at least get the patient where we need them to go? Sure, it might hurt my delicate ego to be wrong, but at least the patient is where they need to be. There’s no harm in that.

Or is there? What about the harm that comes to the patient from the misdiagnoses? The extra irradiation and/or procedures? The additional time/energy/money that needs to be invested into their care? The opportunity cost lost by using resources to determine the correct diagnosis that could have been better used? And if emerg doctors turn into nothing more than effective disposition machines, are we any better than a good triage system?

In the end, we broke the rules, quit playing the game and concluded with the obvious: both disposition and diagnosis are important and which is more important depends largely on the patient’s situation.

In the very sick, disposition takes precedence – we need to recognize the sick and get them to where the need to be at all costs. We can’t let them walk out the door! In the less sick, diagnosis takes precedence – we need to arrive at the diagnosis to treat them as effectively as possible. It may not be ideal, but if we’re wrong they can come back or go see someone smarter.

But in the game, that answer is a cop-out. We see tons of mildly ill patients for every extremely ill patient we see. So back to the game: which would be worse?

Would you rather always misdiagnose or always misdispose?

If you enjoyed this post please tweet/retweet the hell out of it, e-mail it to your twitterless friends/colleagues, follow me on twitter, sign up for my RSS feed (top right corner – it seems to work better to sign up when using Explorer or Firefox; Chrome hates me), sign up to receive e-mails after each post (right column), and/or leave comments.

Thanks again for all of the support over the past few months!

Brent Thoma @boringem

PS – Shout-out to Dr. Mark Wahba for inspiring this post! Check out some of his spectacular posts on openmedicine.com here.

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One Comment
  1. Pik Mukherji permalink

    I think your initial instinct was the correct one. Pt. outcome is the target and dispo home implies safer outcome. Ie. Even if there is diagnostic uncertainty, the ddx is benign when you dc a pt. and get the dispo right. Your concern about testing and misdiagnosis is accurate only if you DO a lot of testing and pursue a dx. The flip side is a correct dx and an admission that serves no purpose. If admission was required to r/o a potentially serious dx, then admission reasonable. But dx certainty with wrong dispo seems like it will ALWAYS be a misfire. Either the sick go home or you waste resources.

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