Make an accurate diagnosis even if... How to understand that the doctor has made an incorrect diagnosis: a reminder for the patient. We establish a preliminary diagnosis by the shade of the tongue

Often in medical practice we have to deal with cases when the patient cannot be given the correct diagnosis. Typically, such patients are either referred from one doctor to another in a circle, sent for more and more tests, but the correct diagnosis cannot be made.

...you shouldn’t meekly go with the flow, but urgently need to start actively influencing the situation...

Let’s make a reservation right away that no matter how cynical it may sound, the absence of a diagnosis is much better than an incorrect diagnosis, because in the latter case the patient will be prescribed the wrong treatment and will be treated, being sure that the symptoms will soon disappear, but in fact they will getting stronger and stronger. It’s even worse if incorrect symptomatic treatment temporarily reduces the severity of the symptoms and the patient is sure that everything is going fine and the longer he is “treated” like this, the worse the situation will be and the more aggressive and traumatic treatment will be required.

In the worst situations, the disease can become incurable and the patient's survival prognosis will decrease from several decades to several months.

Therefore, if such a situation arises, then you should not meekly go with the flow, but you must urgently begin to actively influence the situation.

Causes

The situation described above could be the result of one or more of the following reasons:

Low qualification of the doctor. It is important to understand that many people have the opinion that a young doctor is bad, because he has no experience and knowledge, and an elderly doctor is good, absolutely false. The fact is that older doctors often completely stop developing, learning new techniques, monitoring disease research, and as a result, they lag behind the times for many years, sometimes decades. This is a catastrophically long time for medicine. While a young doctor, if he graduates from a good university, already in internship or residency can get acquainted with modern medicine - read the latest clinical recommendations, studies on the effectiveness of drugs, etc. Although young doctors have less experience and can make mistakes . This is also true.
Errors in laboratory and instrumental studies. Often our clinics have rather old equipment, which is somewhat outdated and has a lot of errors. The same applies to laboratory equipment. In addition, the results of examinations can be influenced by how well a laboratory technician or, for example, an ultrasound specialist did their job. If the attending physician receives incorrect data from blood tests or ultrasound, it will be impossible to make a correct diagnosis, especially if these results conflict with other data.
Erroneous interpretation of research results. This can often occur in cases where the doctor is not experienced enough in analyzing the results of MRI or CT scans, especially in the case of infrequent diseases.

What to do?

The first thing to remember is that taking care of your own health is primarily the concern of the patient himself. Therefore, if you realize that you are going in circles, start breaking this vicious circle and first of all get an alternative opinion. To do this, contact another doctor of the same profile with the results of tests and examinations. It is advisable to do this not in the same hospital, because... you may find yourself in a situation where, in solidarity with a colleague, the new doctor will only confirm the impossibility of making a diagnosis and the situation will only get worse. Contact another clinic.

It is necessary that the doctor you go to for a second opinion has a higher qualification. Getting your diagnosis checked by a less qualified specialist may be a route to nowhere. You can also ask to assemble a medical commission. As a result of such brainstorming, the correct diagnosis or the correct direction of searching for such a diagnosis may be born.

If the second doctor has prescribed you a repeat or additional examination, be sure to do them. It doesn't matter that you've already done them. It may be logical to go to another laboratory or do an MRI on a different tomograph. This will eliminate the influence of low-quality equipment and unprofessionalism of workers.

The problem may be in a situation where you need to get a second opinion on the results of a CT and MRI, and you live in a small town where there simply is no second specialist, and if there is, then his qualifications are no higher than that of the first. In this case, it is best to turn to the National Teleradiological Network (NTRS) for help.

Second opinion from NTRS

…getting a second opinion is so quick and easy...

– a network that connects the best specialists from leading clinics and medical institutes of the country, and allows everyone to receive qualified advice from them regarding the results of CT and MRI. You don't have to wait in line, get a referral, or come in for a consultation. All you need to do is upload the scan results to our server and within a day you will receive a detailed description.

Thus, NTRS is the best opportunity to get a second opinion, and, given that for many diseases, tomography is the most accurate diagnostic tool, a second opinion will also mean making the correct diagnosis.

There is no need to waste precious time when getting a second opinion can be so simple and quick.

YOUR CORRECT DIAGNOSIS

The most important thing in medical treatment is to identify the cause that destroys human health. The doctor, together with the patient, needs to establish, identify, and find the “criminal.” If it is clear which disease is causing suffering, then there is clarity in treatment. Once the diagnosis is made, further action is easier. But making a correct diagnosis is not only the most important thing in clinical medicine, but also the most difficult. Despite the achievements of modern medicine, the emergence of expensive diagnostic systems, despite all the efforts of medical workers, unfortunately, it often happens that we fail to catch the “criminal”. When there is no accurate, correct diagnosis, the doctor has to act blindly, and the treatment prescribed in such situations often turns out to be ineffective.

Sometimes a person’s illness is so complex that sometimes even a pathologist in a section after a death, having the opportunity to look into any corner of the body, cannot say what the person was sick with. Sometimes the pathologist, who is the last resort, cannot make the correct final diagnosis. The cause of death in such situations is established as the most probable.

An experienced clinician differs from a less experienced one in that the less experienced one gets the greatest job satisfaction when he cures a patient. A more experienced doctor also rejoices at the recovery of a large person, but he experiences the greatest satisfaction when he makes the correct diagnosis of a difficult patient, when he catches a “criminal” and “puts him behind bars.”

The overwhelming majority of patients are convinced that making a correct diagnosis is the responsibility of doctors alone. They are sure that absolutely nothing depends on them here. This is a typical mistake, an unfortunate misconception.

If the doctor and the patient work together on the diagnosis, the diagnosis becomes more accurate and correct.

What can a patient who does not have a medical education do to ensure that the diagnosis is made correctly?

First of all, he must include himself in the team of medical professionals who care for him. He must become a full-fledged partner, a member of the team, he must play an active role in the diagnostic and treatment process, and not be a passive observer. The quality of information and the accuracy of the data on the basis of which the doctor makes a diagnosis depend on the patient. How correctly the patient can convey to the doctor what is happening in his body, the correct his diagnosis will be. If these data are crooked, so will the diagnosis. It has already been noted that uncertainty is part of medicine. The patient can reduce this uncertainty.

In previous chapters, I have already dwelled in detail on what and how the patient should give to the doctor so that the doctor makes a full, correct diagnosis. Here I deliberately used the verb “to give”, realizing that the phrase can be interpreted in two ways. Provide accurate, objective, complete information about your disease and yourself. No one knows your body and the peculiarities of its reactions better than you. Only you know what is most important to you. As noted, the doctor cannot feel the disease for you. The doctor only helps convey to the patient the manifestations of the disease. Being clear about what is happening to you is very important. Sometimes this can be difficult for the patient to do. Most often, patients give either too little information or overload their speech with details that are completely irrelevant.

It is necessary for the patient to strive for clarity of presentation, since the correctness of the diagnosis depends on it.

After the doctor has analyzed the data received and told you your diagnosis, ask on the basis of what data he came to this conclusion. Let him convince you that you have exactly the disease he is talking about. In the vast majority of cases, this can be done in two or three simple sentences. If the doctor speaks firmly and in words that you understand, the “criminal” is caught. If you see doubts, hesitations, dissatisfaction, and sometimes verbosity of a conscientious, competent, experienced doctor, then the diagnostic search may have to be continued. Here, without even delving into the meaning of what was said, but by the way the doctor answers your question about the reliability of your diagnosis, you can judge with a high degree of probability its validity.

Quiet confidence is what an intelligent patient should see from his doctor, asking him to reassure him of the correctness of his diagnosis.

If you are a “complicated case” and are diagnosed as most likely, do not hesitate to ask your doctor what other diseases may cause these symptoms. This will help the doctor take a broader look at the problem, “cast the net” more widely, do additional work on the differential diagnosis, and be more creative. Let his thought process, his “agony” when making a diagnosis, be in front of you. This will allow you to get involved in the search process. Ask your doctor what else you can do to confirm the diagnosis. What should be your next steps to catch the “criminal”.

An important and well-proven technique for difficult diagnoses is a second opinion. If you are given the most likely (approximate) diagnosis and it is not completely clear what exactly is happening to you, it is advisable to consult another doctor. This does not mean that the first doctor is bad. Clinical medicine is full of uncertainties. Different doctors have different experiences, different schools, they think differently. It may well be that the second doctor already had a patient with similar problems, which he was able to solve. The second doctor may turn out to be more “corrosive” or more interested in this branch of medicine. In difficult situations, third and fourth opinions are not excluded. According to American doctors, a second opinion changes diagnostic and treatment tactics in 1/3 of cases! A good clinician will never be offended if you tell him that you want to see another doctor.

For particularly difficult diagnoses, it is advisable to consult with specialists of a narrow profile with extensive experience. As a rule, in such cases, the patient should contact large medical research centers that specialize in certain areas of medicine. It is best for the patient to search for such centers together with his or her attending physician. Sometimes the problem can only be solved in our capitals, and sometimes only abroad.

Monitor your body's reactions. Be proactive if your prescribed treatment doesn't help or if you feel worse. Let your doctor know about this. There should be a strong communication between you and your doctor. In such a situation, do not try to complete the entire prescribed course of treatment or complete it. This may be because you are being treated for another illness. It happens. Find out with your doctor the reason why treatment is not working. Perhaps it is too early to expect improvement, and the deterioration is due to the work of the drug. Or perhaps your diagnosis is incorrect and you should continue your diagnostic search.

In our country, there are few organizations that actually protect the rights of patients, and there are no structures at all to help patients get involved in the diagnostic and treatment process. In this regard, our patients must be much more active than, say, in developed countries where such structures exist. For now, everything is the other way around.

Medical professionals in Western countries are better trained, more motivated, better equipped, but their patients, who might seem like they could relax, are much more active than ours. That's why people in the West live longer.

Understanding that much depends on the patient in identifying the disease gives him the opportunity to live longer.

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Gaevsky Yuri Germanovich, Doctor of Medical Sciences, Professor of the Department of Internal Medicine, Neurology and Psychiatry of NovSU

Throughout his entire medical life, starting from a rural district hospital and further in large clinics, in the process of working and teaching he was engaged in
issues of diagnostic methodology and teaching clinical diagnostic thinking skills.

What is disease diagnosis? This is the identification of the image of the patient’s illness with an abstract image of a particular disease. An abstract image of a disease may consist of signs that always occur in a given disease and do not occur in others.

That is, the sensitivity and specificity of these symptoms is one hundred percent. This symptom is the gold standard for diagnosis: if it exists, there is a disease. Without it, there is no disease. Unfortunately, such symptoms are few and far between. These may also be simple physical symptoms, for example, a diastolic murmur at the apex with mitral stenosis or a diastolic murmur at the aorta with aortic valve insufficiency. And complex hardware or laboratory facilities. Other symptoms always occur with this disease, but often occur with others - sensitive, but low specific.

An even larger part in the image of the disease is occupied by the symptoms that can only be present in a given disease, having low sensitivity and specificity - far less than one hundred percent. Identification of a patient's disease pattern is successful provided that the patient has all the symptoms that should be present. All other symptoms found in the patient may also be associated with this disease. The patient has no symptoms that are not described for this disease(1).

The search for the correct diagnosis is very close to the search in criminology. Perhaps that is why the prototype of Sherlock Holmes was the famous doctor.

Let us give an illustration of this.

Imagine that in a big city there is a search for a car that hit a passenger. According to witness testimony, the brand, series, color and presence of a dent are known. The car may have traces of blood or pieces of the victim's clothing. Simple “physical” symptoms are used to search. Five hundred cars were selected from the traffic police file, using color, make, and series. After examining them, they found thirty cars with a dent. Fifteen found traces of blood. In three of the spots the blood type matched the patient's blood type. One of them has a 100% alibi - he was in another city (that is, there is a symptom that should not exist). Genetic identification of the blood stains and the victim was carried out. In one case it's a coincidence. The culprit has been found. No match was found - the diagnosis fell apart. Reason: the witness mixed up the color of the car. A false positive symptom got into the version and ruined it like a Trojan horse. All symptoms participated equally in the search: at the first stage, simple, but highly sensitive. The last stage is complex, but with high specificity. Of course, it was possible to immediately check fifteen for genetic identification? But this is long and expensive. Although this is a symptom with one hundred percent sensitivity and specificity.

So, clinical diagnostics consists of the stage of collecting information and the stage of forming a diagnostic conclusion. The data can be divided into simple clinical ones: anamnesis and physical examination data. Routine hardware-laboratory and special. The most important principle of the culture of clinical diagnostics at this stage is the following: the value of a symptom is not determined by the modernity of the equipment with which it is obtained, but by its sensitivity and specificity. And also the reliability of its receipt. In this regard, the value of simple anamnestic and physical data is high and, along with routine and complex ones, they are equally involved in making a diagnosis. That is why it is so necessary to improve the art of taking anamnesis, examination, percussion, palpation, and auscultation.
In summary, simple clinical techniques for obtaining information are valuable for the following reasons.

With an algorithmic and non-algorithmic approach, they help to narrow the range of possible diseases already at the very initial stage and provide direction in prescribing the only necessary special studies.
Possession of them provides enormous advantages in emergency situations of night duty, emergency room and ambulance work.
The low sensitivity and specificity of simple symptoms is compensated by their number. The probability is summed (4). This gives reliability to the diagnosis. Simple ones duplicate complex ones. Their coincidence makes the conclusion reliable. Their discrepancy forces us to double-check the data from special studies.
They are also invaluable in terms of daily monitoring of the dynamics of the disease.
Only a study of the dynamics of complaints, anamnesis and physical data makes it possible to create a complete spatial and temporal image of the disease.

Having this image makes it easier to handle second-hand information. Suspect and double-check it for false positives or false negatives in time and make the right diagnostic decision.

Example

A 41-year-old patient notes increasing shortness of breath during the year when walking. In the last month there have been two episodes of loss of consciousness while playing tennis. On auscultation there is a rough systolic murmur in the aorta. When conscripted into the army and before, no heart murmurs were found.

Preliminary diagnosis: aortic valve calcification with critical stenosis and syncope.

Echocardiography confirmed the diagnosis completely.

Simple physical findings and history provided an almost definitive diagnosis.

Example

The patient is 47 years old. There are no complaints, he was examined prophylactically. ECG is normal. There is a slight systolic murmur on the aorta.

Echocardiography revealed calcification of the aortic orifice with supposedly significant stenosis. This discrepancy between simple and special data forced a joint re-study.

The conclusion about stenosis was erroneous.

This is a good lesson: before the examination, look at the ECG, talk to the patient, listen to the heart.

Example

The patient is 16 years old, no complaints. During examination, a quiet, high-pitched diastolic murmur was accidentally discovered at the Botkin-Erb point. The mild degree of aortic insufficiency did not raise any doubts. However, during the first echocardiographic study, aortic insufficiency was not detected. Repeated joint examination revealed a rare pathology - aortic valve prolapse with its insufficiency.

Auscultation of the heart is mandatory before echocardiographic examination.

Example

The patient is 38 years old. He was admitted to the intensive care unit with acute chest pain that began about five hours ago. ECG shows ST elevation in chest and standard leads by 2-3 mm. with shallow negative T waves. The troponin test is positive. It would seem that the diagnosis of myocardial infarction was not in doubt. However, attention was drawn to a rise in temperature to 37.4 degrees, which during a heart attack occurs no earlier than the second day of illness, and a close connection between pain and breathing (which cannot happen during a heart attack). This allowed us to make and later confirm the diagnosis of viral pericarditis.

Simple clinical symptoms played a decisive role in making the correct diagnosis.

Example

A 25-year-old patient was admitted with high fever, pain in the right side when breathing, percussion dullness on the right side under the scapula and bronchial breathing. The diagnosis of lobar pneumonia was not in doubt, but the attending physician was of the opinion that there was acute pyelonephritis, since the radiologist found no abnormalities, and there were leukocytes in the urine.

A joint review of the radiographs showed typical lobar pneumonia, which was not described due to a misunderstanding. Simple clinical data allowed us to avoid an annoying mistake.

Example

A 30-year-old patient was admitted with complaints of weight loss and constant pain in the right hypochondrium. On deep palpation, a dense, immobile formation under the right lobe of the liver was palpated uncertainly. An ultrasound examination revealed diffuse liver changes similar to chronic hepatitis. Repeated joint ultrasound examination revealed a tumor in the retroperitoneal space. False-positive information about hepatitis contradicted the palpation data and this made it possible to avoid a fatal mistake.

Example

The patient is 50 years old. Suddenly, at work, I felt an acute pain in the chest, from which I lost consciousness for several seconds. The pain continued and he was taken to the emergency room. On the ECG, ST elevation in the precordial leads is 4-5 mm. Cardiac arrest occurred in the emergency room and successful resuscitation was performed.

The diagnosis of myocardial infarction was not in doubt, but attention was drawn to strange symptoms: the acute onset of the disease and the presence of a quiet diastolic murmur in the aorta. A dissecting aortic aneurysm was suspected. Hypotension was maintained. On the seventh day, the patient suddenly died from cardiac tamponade. The diagnosis of dissecting aneurysm was confirmed.

In the next article we will dwell in more detail on the second stage of diagnosis - direct diagnosis.

Yu. G. Gaevsky,
Doctor of Medical Sciences, Prof.

Doctors are called to help people. Unfortunately, in difficult situations they are not always able to save the patient, because the countdown is in seconds, and every decision made can turn out to be fatal. Judging doctors for not being able to heal everyone is wrong because they are only human.

However, in some cases, a disastrous outcome could have been avoided if not for the negligence and inattention of medical personnel. Such behavior must be stopped and the culprit must be punished. After all !

So what should you do if your doctor makes the wrong diagnosis?

Features of the crime

Cases involving medical malpractice are considered some of the most complex cases in legal practice. Patients are often dissatisfied with the work of doctors, but do not always decide to start proceedings, because in order to establish that a medical employee is wrong, evidence is needed.

So, it is necessary, first of all, to establish whether the diagnosis was made incorrectly due to the doctor’s fault (due to his inattention or). For this purpose, a medical examination is carried out.

Experts, using test results, recreate the situation in which the accused doctor found himself when making the diagnosis. If, based on these data, experts conclude that any doctor of appropriate qualifications could make the correct diagnosis, there are grounds for calling the negligent doctor accountable.

Thus, making an incorrect diagnosis is punishable when it was made through the fault of the doctor. This could be simple laziness, ignorance (cases of professional illiteracy are not uncommon), inattention or a biased attitude towards the patient, in a word, an irresponsible attitude towards one’s responsibilities.

To learn about why an incorrect diagnosis made by a doctor is so dangerous, watch the following video:

Algorithm of patient actions in case of a medical error

When a patient has reasons to suspect that he was diagnosed incorrectly (most often, this becomes clear from the deterioration of the person’s condition), this assumption should be confirmed or refuted.

Where to contact?

There are several authorities that you can contact if you discover an error on the part of the attending physician.

It is most logical to start with the administration of the hospital itself, since if you immediately contact higher institutions, you will still be redirected there in order to find out the circumstances on the spot.

Administration of a medical institution whose doctor made an incorrect diagnosis

The first thing you need to do is write a complaint to the head of the department where you were treated incorrectly, or directly to the head physician if the situation is complicated.

Most often, problems that arise are resolved at this stage. The doctor’s actions are reviewed by management, and if they are found to be incorrect, your claims are satisfied.

If the hospital administration does not cooperate and refuses (the response to the complaint must be in writing), you should complain further.

Ministry of Health

A territorial branch of the Ministry of Health can be found in every subject of the Russian Federation. This body always has a public reception room where complaints from the public are accepted for consideration. After all, the purpose of this organization is to control the work of medical institutions.

There are several ways to file a complaint with the Ministry of Health:

Personally;
Send the paper by mail;
Send a letter of complaint by e-mail;
Leave the text of the complaint on the official website.

As in the case of the hospital administration, they must answer you, and in the form that you indicated in the complaint. The application is given 30 days to review.

Prosecutor's office

Since the duties of the prosecutor's office include monitoring compliance with the current legislation by citizens and organizations, filing a complaint against a doctor with this body is quite natural.

Court

To defend their rights, each person can file a claim in court. However, you should remember that your claim must be substantiated and supported by evidence in the form of a sick leave certificate, outpatient card, test results, and prescriptions.

It is with the help of the court that one can achieve compensation for damage when the management of the clinic refuses to solve the problem peacefully.

Financial compensation in favor of the plaintiff will be requested from the organization where the doctor who made the incorrect diagnosis works. After which the hospital can recover these funds from the negligent employee.

The claim is filed in the usual manner. All necessary documents are attached to it.

Police Department

In some cases, medical negligence leads to significant consequences, described as grave harm, the infliction of which by negligence is punishable under Article 118 of the Criminal Code of the Russian Federation.
In addition, the reason for contacting the police may be negligence (Article 293), non-compliance with accepted sanitary and epidemiological standards (Article 236) and concealment of certain circumstances that led to a deterioration in human health (Article 237).
Cases of intentional infliction of serious harm are extremely rare (Article 111).

The fact that you are being treated incorrectly should also be reported to the insurance service, which will provide an examination.

If the mistake was made by a doctor in a private clinic, all of the above measures also apply. In addition, you can contact the Rospotrebnadzor office, which monitors the work of all enterprises and legal entities.

Rules for filing a complaint

There is no fixed sample of a complaint against a doctor (including a pediatrician) about an incorrect diagnosis, so we will name only a few recommendations for its preparation, which will allow all the facts to be succinctly and accurately presented:

Statement header. It is written, as is customary, in the upper right corner of the sheet. This should contain the following information:
- Names of the body to which this complaint is sent;
- Full name and position of the person to whom the paper is addressed;
- Personal data including full name, telephone number and address;
In the center of the sheet, under the header, you must indicate the name of the document: “Complaint against a doctor” or “Claim”;
Main part. Here you need to briefly and succinctly state the situation, if possible, refer to the law that, in your opinion, has been violated. Here you should point out the available evidence;
Filling out claims (taking measures in connection with negligent attitude towards the work of medical staff, calling for responsibility, punishment, compensation for damage);
Date and signature of the applicant;
List of attached documents.

You can find the rules for filing a claim in court in Article 131 of the Code of Civil Procedure of the Russian Federation. In principle, it will contain the same information. In addition, it will be necessary to indicate the fact that pre-trial measures were taken, that is, an attempt to resolve the issue with the hospital administration before filing a claim.

Read last about what a doctor faces for an incorrect diagnosis in accordance with the legislation.

Responsibility of the doctor and medical institution for incorrect diagnosis and treatment

Doctors are rarely convicted of criminal liability for an error in prescriptions that led to serious consequences for the patient’s health, and for criminal negligence, and, as a rule, such a case receives wide resonance.

Our body often gives us certain signals about a disease. Absolutely any disease has a number of certain signs, which are called. In order to make a correct diagnosis, you need to identify them. This process is called diagnosis.

General concepts of diagnosis

What does such a thing as “diagnosis” mean in medicine? This is nothing more than recognizing an illness. Moreover, this is not only the disease itself, but also the results of the patient’s examination, which allow the specialist to move from thinking to treatment.

When making a diagnosis, the specialist is guided by the applicant’s complaints (symptoms), examination of the patient and test results. This takes into account gender, age, place of residence and other non-medical factors.

It is customary to distinguish several types of diagnoses in medicine: clinical, pathological-anatomical, forensic, epidemiological.

How to make a diagnosis based on symptoms?

Previously, only people who had a special medical education could make diagnoses, but after the Internet entered our lives, many of us began to diagnose ourselves and prescribe medications for ourselves. This is not good, because without being a professional in this matter, you can easily make a mistake in making a diagnosis, and this can lead to serious consequences.

First of all, you need to carefully monitor. Its rapid decrease can signal many ailments, for example, hyperthyroidism (excessive secretion of thyroid hormones). Young women are very often affected by this disease. As for older people, sudden weight loss may indicate malignant tumors.

If you are sick, then observe how long your cough lasts. If this continues for more than 3 weeks, it may indicate a serious condition. For example, bronchial asthma, tuberculosis, pneumonia or other oncological diseases.

How to diagnose by language?

In normal condition, our tongue should be pink in color, have a small coating and a weak one, which can be easily removed with a toothbrush. If it begins to thicken over time and acquire a yellowish or gray tint, this indicates reduced immunity.

By the way, if you find a white-yellow coating the next morning and it can be easily removed with a brush, then this is not a reason to panic. And if this could not be done, then this may indicate a fungal infection, various diseases of the oral cavity or dysbacteriosis.

A pale coating may indicate anemia, but another symptom can also be identified: fatigue.
If you have a gray coating, this may indicate that your body does not have enough iron.
With low acidity, it is slightly enlarged and has a pale coating, and with low acidity, on the contrary, it is slightly reduced and drier.
A yellowish color may indicate liver pathologies.