Patients do not like leaving the ED without receiving a definite diagnosis, according to the authors of a recent study.1
However, this kind of closure is not always possible in the ED, where many people are sent home with a symptom-based diagnosis such as “abdominal pain.”
“In many cases, patients are discharged without a sufficient explanation of what’s occurred during the visit and what to do about their symptoms,” notes Kristin Rising, MD, one of the study’s authors. Rising is an EP at Thomas Jefferson University Hospital and associate professor of emergency medicine at Thomas Jefferson University, both in Philadelphia.
In their analysis of 30 recently discharged ED patients, Rising and colleagues found that most patients’ primary reason for coming to the ED is to receive a diagnosis.
“This study was focused on what struggles patients have when they haven’t yet received a ‘real’ diagnosis, and the diagnosis they receive is a re-statement of their symptoms,” Rising explains.
Even if a clear-cut diagnosis is not possible, ED personnel can address the patient’s associated needs, Rising and colleagues suggested. Many patients voiced the need for better explanation for why they did not receive a diagnosis. They wanted to know why it was safe to leave the ED without one.
“Patients repeatedly highlighted a need for more effective communication with providers,” Rising says. This includes identification of who was in charge of their care or discharge, test results, and reasons why certain tests were not ordered. Currently, Rising is developing a standardized approach for patients who are discharged without a definite diagnosis, including:
- a clear statement to patients that a definitive diagnosis has not been identified;
- a description of alternative diagnoses that were considered and how they were ruled out.
Without this knowledge, when bad outcomes happen, it is easy to suspect the ED provided poor care. A call to an attorney is not far behind. One patient discharged without a diagnosis stated, “I think because of the type of healthcare that I have, I was not given the best of services.” Others reported that lack of information made them feel inadequately treated and generally dissatisfied. “All of these things potentially decrease patient trust in providers and the system as a whole and may increase their desire to seek legal action in the setting of bad outcomes,” Rising adds.
The fact that EPs do not know “the whole story” often becomes a defensive tactic during malpractice litigation. A defense attorney will remind jurors that EPs cannot be responsible for what they are not told or what clinical information they cannot quickly access.
“This, many times, will resonate with jurors,” says Robert Hanscom, vice president of business analytics at Coverys, a Boston-based provider of medical professional liability insurance. However, it is the EP’s duty to ensure the patient receives the correct treatment. If this standard of care is not met, the plaintiff’s case is stronger.
“This is true even though the ED physician’s relationship with the patient is compacted into a relatively short period of time,” Hanscom notes. Typically, EPs rapidly treat a substantial volume of patients, making many time-pressured decisions throughout their shifts. “It is an intense environment; sometimes, they are dealing with limited information,” Hanscom says. “The ED defense team often cites the nature of the ED as a big part of their case.”
Often, EPs are wary of speaking up about uncertainty, fearing it will expose them legally. “It, in fact, does quite the opposite,” Hanscom argues. “I’m a big believer in being completely candid with the patient.”
Hanscom suggests this wording: “Your symptoms are somewhat unusual. If they were just [blank], we could quickly say it is [blank]. But you also are experiencing these problems. Those do not usually present themselves with this diagnosis. To be candid, it is not exactly clear what is going on here. But we will make sure there are steps taken to get to the bottom of this. Here’s the plan to move that forward.”
Documenting the uncertainty, the discussion, and the plan in the ED chart is helpful to the defense. Conversely, remarks such as “it is just a sprain” when the X-ray is less than definitive are going to be legally problematic if it turns out to be a fracture. The EP then must admit at trial or deposition that, in fact, the diagnosis was uncertain. “Uncertainty should always be communicated, documented in the record, and should be followed up by next steps to get to a more certain state,” Hanscom adds. Patients then become more engaged in their own care. This becomes very important for time-sensitive diagnoses such as myocardial infarction, stroke, or aneurysm.
“If a physician conveys confidence surrounding a diagnosis when they’re actually unsure, they set themselves up for liability,” Hanscom says. This is because the EP is providing potentially incorrect and damaging information. “By acting with full transparency, you lower the risk of adverse results and create a path to the correct diagnosis,” he adds.
According to Hanscom, these are categories of diagnoses that cause the most trouble for EDs legally:
- Emergent issues that are potentially life-threatening if not resolved. “Doctors must be on especially high alert for potential symptoms of these conditions, as the severity of the potential injury is extremely high,” Hanscom warns.
- Missed fractures, such as a minor break miscategorized as a sprain. “While these are often not as high value, if an injury results in permanent impairment, it could certainly result in a substantial payout,” Hanscom cautions.
- Situations in which EPs order tests to determine a diagnosis, but the patient is discharged before results return. If someone is sick enough for the EP to order tests such as blood cultures, the patient ideally should not be discharged until the test results have been received and reviewed. “There may be potentially serious consequences for the patient, especially if the ER physician cannot get in contact with them right away,” Hanscom explains.
- Misreporting, or not reporting, incidental findings. For instance, a routine chest X-ray may reveal a lung spot that requires further tests. “If the ED physician fails to ensure that the finding is seen by the provider following the patient on an ongoing basis, they could be named in a suit should that result in a failure to diagnose,” Hanscom says.
- Gerolamo AM, Jutel A, Kovalsky D, et al. Patient-identified needs related to seeking a diagnosis in the emergency department. Ann Emerg Med 2018;72:282-288.