On Thursday, I had an experience-based hunch about the Dallas Ebola case:
Who missed Ebola? I assume nurse entered travel history into electronic record & doctor didn't grasp significance. Will any reporter ask?— Steve M. (@nomoremister) October 2, 2014
Also, docs are taught "When U hear hoofbeats, think horses, not zebras." Leads them to dismiss possibility of rare conditions. @nomoremister— Steve M. (@nomoremister) October 2, 2014
Then we learned -- or thought we learned -- that the intake software didn't present Thomas Duncan's travel history to the doctors. Now we find out that wasn't true:
Dallas Hospital Alters Account, Raising Questions on Ebola CaseLet me venture a guess as to what happened, based on recent (and not-so-recent) experiences with the health care system.
... the hospital that is treating the patient and that mistakenly sent him home when he first came to its emergency room acknowledged that both the nurses and the doctors in that initial visit had access to the fact that he had arrived from Liberia.
For reasons that remain unclear, nurses and doctors failed to act on that information, and released the patient under the erroneous belief that he had a low-grade fever from a viral infection....
It's true that a lot of medical professionals are still getting used to electronic record-keeping. They probably haven't developed an instinct for where to look on the screens for the most important information.
On the other hand, long before electronic record-keeping in medicine, I noticed that doctors barely read any patient information before seeing someone. Quite a few times over the years I've been asked to get a test of some kind -- usually a blood test -- and then, when I showed up for a follow-up visit, often weeks after the test results were sent to the office, I watched the doctor skim the results in a few seconds just after entering the examination room to see me.
Doctors don't familiarize themselves with written information before seeing patients. To me it seems that they diagnose on observation, experience, and instinct far more than on data.
Plus, they've been told since med school to diagnose following the dictum "If you hear hoofbeats, think horses, not zebras." This advice is supposed to tell them: Consider common conditions first, before considering rare ones. In practice, I believe most doctors interpret it as: Don't trouble your head with rare or unusual diagnoses.
I may be misinterpreting how doctors work, but I've had a couple of long periods in my life when low-level but nagging conditions were repeatedly misdiagnosed, and this is what I've seen: not much attention paid to data, and not much willingness to consider less obvious diagnoses.
I think that's what happened in Dallas -- the doctors didn't read, and Ebola was assumed to be a zebra. That mustn't happen again.
(More responses to this story at Memeorandum.)