We’re a Kaiser Permanente family. I’ve been a member since before college, apart from a few employment-related coverage gaps. Our daughter, Sara, was born at a Kaiser facility on Geary Street, where my wife, Debbie, received excellent prenatal care. My elderly parents are regular users of the health maintenance organization.
Kaiser is structured around gatekeeper primary care physicians, who treat non-emergency medical needs, sometimes after a telephone consultation with an advice-nurse. Primaries have the power to refer patients to specialists: orthopedic; ear, nose, and throat (ENT); medical imaging; physical therapists. Savvy Kaiser members know that having an accessible, responsive, primary is essential to managing their care. The best ones can be in heavy demand, with long waiting lists of would-be patients. Even with a user-friendly primary, members often struggle through a series of administrative hurdles to secure proper attention.
Over the past couple of years Debbie and I have had similar Kaiser experiences that prompted us to question the quality of care. Mine came first. Skiing at Palisades, downslope from the top of Red Dog chair, I caught an edge, and fell face down, jamming the handle end of my pole into my chest. My heart raced; I couldn’t catch my breath. I skied to the bottom, and went to the onsite clinic. The doctor confirmed that I’d bruised my chest, but after listening to my heart sent me on my way.
The next day, walking up a modestly steep hill – by San Francisco standards – my heart started racing again. I couldn’t catch my breath. I flywheeled a taxi and asked the driver to take me to Kaiser’s emergency clinic, located next to where Sara was born. After hooking me to an EKG, the ER doctor declared my heart rate “abnormal,” and admitted me to the hospital. A cardiac specialist wouldn’t be available to check me out until the next day.
I spent an uneventful, mostly sleepless, night in the infirmary, tended to regularly by friendly nurses. The next day, the cardiologist monitored an EKG as I jogged on a treadmill. A few minutes into the procedure, he grimaced.
“I keep telling them,” he snorted, referring to the ER staff, “this is an atypical heartbeat, not an abnormal one. You’re fine. They shouldn’t have admitted you.”
The cardiologist offered to let me take a few more tests, but it was clear whatever episode I had was over. I thanked him and fled.
According to Improving Diagnosis in Health Care, published in 2015 by National Academies Press,
Diagnostic errors—inaccurate or delayed diagnoses—persist throughout all care settings and harm an unacceptable number of patients. Getting the right diagnosis is a key aspect of health care, as it provides an explanation of a patient’s health problem and informs subsequent health care decisions. Diagnostic errors can lead to negative health outcomes, psychological distress, and financial costs. If a diagnostic error occurs, inappropriate or unnecessary treatment may be given to a patient, or appropriate—and potentially lifesaving—treatment may be withheld or delayed…Absent a spotlight to illuminate this critical challenge, diagnostic errors have been largely unappreciated within the quality and patient safety movements. The result of this inattention is significant: It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences.
Recently, Debbie felt a sharp pain in her left ear, followed by a dull throbbing, and Tinnitus. The pain took root; she had a hard time hearing. After speaking with an advice-nurse she arranged to visit her primary care physician at Kaiser’s Mission Bay facility, who, after examining her ear, prescribed drops. Two days later the pain, hearing loss, and high-pitched tone remained unabated. She returned to Kaiser, where the doctor surmised that the problem was a bacterial infection and prescribed a weeks-long course of oral antibiotics. Another four days passed – nearly a week into her searing earache – and her symptoms remained the same, worsened by the turmoil in her stomach caused by destruction of probiotics.
“This isn’t working,” she grumbled. “I need to see an ENT.”
She emailed her doctor and called an advice-nurse, who sympathized with her plight.
“There’s nothing worse than ear pain,” said the nurse. “I’ll message your doctor to request an ENT appointment as soon as possible.”
After more pleading communications to her primary care physician Debbie fought her way into seeing an ENT, who carefully examined her ear.
“I keep telling them,” she grunted, referring to the primary physicians, “it’s more often than not a buildup of wax. You don’t need antibiotics. You need your ear suctioned. They could have done this when they first saw you.”
After syringing Debbie’s ear with diluted hydrogen peroxide, the ENT vacuumed out a clot of wax. The pain subsided immediately, Debbie’s hearing returned, and, after another day, the ringing disappeared.
Debbie’s and my misdiagnoses didn’t threaten our lives, or cost all that much money, though a night in a hospital isn’t cheap. But the identical nature of the specialists’ complaints caught our attention. How often does their guidance go systematically unheeded, at Kaiser or any other medical provider? And how often does a basic diagnostic mistake lead to something worse than an upset stomach and a week of unnecessary pain? It’s in all our interests to answer these questions, and act on what we learn. Periodically, the health care system needs to unclog its ears with the right medicine.