1. A STUDY OF ANECDOTES ON OVERSIGHTS IN PHYSICAL EXAMINATION

 
Thank you for participating in this short, 11 question, qualitative study.

We are looking at a type of medical error that is poorly studied; unlike wrong-site surgery or medication error, OVERSIGHTS IN THE PHYSICAL EXAM that have consequences are not easily quantified. We believe that narratives or anecdotes of such incidents, when collected in numbers, are the best way to capture this phenomenon. By collecting these anecdotes we can then analyze and characterize the nature of such oversights and their consequences.

The focus of our study is errors, omissions, misinterpretations, inability to seek or link associated findings, or other failures in the PHYSICAL EXAM, rather than problems in history taking, although we understand that these oversights in the physical exam may stem from or may be facilitated from poor history taking. Our focus is on physicians alone(not medical students).

By the physical examination, we do not mean just the initial physical examination of a new patient, but any time there is an opportunity to examine the patient for diagnosis, for consultation or for monitoring treatment.

We are interested in oversights in the physical exam, regardless of whether these are unique, rare, common, or very common. We are not necessarily trying to record bizarre or rare stories only. Also, we are interested by and large in anecdotes that you are aware of from first-hand experience, or else heard about reliably from physicians in your team.

Also, we are not interested in situations where the physical exam was performed fully appropriately, but the findings were misleading simply because specific signs in the physical exam have imperfect sensitivity and specificity for making a diagnosis

Question Title

* 1. IN A SENTENCE OR TWO, TELL US ABOUT THE OVERSIGHT IN THE PHYSICAL FINDINGS THAT WAS AT ISSUE?
(example, "Neurofibroma overlooked on exam" or "Obvious congestive heart failure mislabeled pneumonia" or "Patient had murmur of aortic regurgitation that was overlooked.)

Question Title

* 2. PLEASE DESCRIBE IN NARRATIVE FORM EXACTLY THE NATURE OF THE OVERSIGHT. IT CAN BE FROM 100 TO 200 WORDS AS IN THE EXAMPLES BELOW:

EXAMPLE 1: A patient was admitted for continuing treatment of a lung condition. Over the phone, the resident reported to the the attending that the patient had multiple ‘masses’ in the belly which the resident could not characterize further. The resident could not say whether the "masses" were intra-abdominal or in the abdominal wall, and could not say much about the size. The next day on attending rounds it was obvious that the patient had neurofibromatosis. The skin tumors were easily palpated wherever one applied a hand. Since the only part of the body palpated by the resident was the abdomen, these subcutaneous nodules were called "abdominal masses." By the time the attending made rounds, the patient had already been sent for a CT of the chest and abdomen with contrast in order to evaluate the "masses." (Incidentally, the patient, if asked, might have volunteered the history that these bumps were present forever and other family members had them. However, our focus is on the physical, not the history in this study).

EXAMPLE 2: A male patient in his fifties presented with right shoulder pain. Over the course of five weeks saw multiple physicians, including ER, primary care, orthopedics and also had many studies including plan x rays, CT scans, MRI. Eventually one of the imaging tests happened to show quite by accident the presence of an apical lung lesion. The pulmonary consultant called in noted that the patient had clubbing of the fingers. On biopsy this turned out to be a cancer with pleural and rib involvement. According to the patient, he had noticed clubbing, painful wrists and ankles, and had even pointed this out to one of the physicians to see him early on, but no one commented on it or made the connection that the patient had clubbing and therefore likely had lung cancer and in this case hypertrophic pulmonary osteoarthropathy.

YOU DO NOT NEED TO ELABORATE ON CONSEQUENCES OF WHAT WAS MISSED AS THAT WILL BE IN NEXT QUESTION

Question Title

* 3. WOULD YOU CHARACTERIZE THE OVERSIGHT AS RESULTING FROM ONE OF THE CHOICES LISTED BELOW?
(For example, a a murmur of aortic insufficiency might be overlooked because the relevant exam was not done or the exam was done but the murmur was overlooked, or the murmur was heard but not recognized as AI or associated clinical findings were not mentioned.)

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