Day 2, psych exam findings, bias, misses

Warning: Long post and a little “soapbox-y”

When I work in the ED, I document exam findings such as “appears anxious”, “dysphoric”, etc often.  While moved by the story of Alyssa’s death, I don’t think the lesson I take away is that documenting “anxious” in her chart was a true contributing factor, and I will continue to document psychiatric exam findings.

My rational is this:

#Though not all physicians are trained or qualified to make psychiatric diagnosis, I do believe that all are trained and qualified to perform an at least basic psychiatric examination and find/document findings such as mood, affect, speech, though process and content (the basic elements of a psych exam).

#The exam findings are IMPORTANT.  A patient who appears anxious may be anxious from their supra-ventricular tachycardia, thyrotoxicosis, cocaine intoxication, or hypovolemic shock.  Anxiety as an exam finding or symptom and does not equal a primary psychiatric condition like generalized anxiety disorder.  Providers must know how to examine patients, document it appropriately, and rely on it when formulating an assessment and plan.  Not documenting an exam finding like anxiety can lead to missing a diagnosis if caused by an organic condition and it can also lead to failure to treat a patient’s anxiety – a morbid condition no mater the etiology.

#The real risk of error lies in the interpretation of the exam finding/symptom into an assessment and plan.  In Alyssa’s case, the finding of anxiety on exam early in her course primed her team/other providers to attribute other symptoms (abd pain, etc) as an associated symptom of psychiatric-related anxiety.  And in the face of evolving and worsening vital signs, symptoms and concern from family/RNs, the provider anchored on anxiety instead of properly reassessing Alyssa and making sure they weren’t missing the right diagnosis.  The provider failed to change treatment course even in the face of no clinical improvement with anxiolytic therapy.  The error is interpretation of the finding and clinical judgement, not documenting the finding.

#Correctly identifying the exam finding/symptom of anxiety as a primary psychiatric condition can spare patients from harm and is an important clinical skill.  For example, if a clinician cannot correctly diagnose a young woman with a panic attack, that patient could undergo a CT pulmonary angiogram for their symptoms of sudden onset anxiousness/shortness of breath/chest tightness/rapid hart rate to rule out a pulmonary embolism.  This CT entails a significant amount of radiation increasing her risk of cancers and exposure to contrast which can damage the kidneys.  Careful examination, history taking and skilled clinical judgment must be employed when evaluating patients with psychiatric findings/complaints in order to provide appropriate level of care that does not over- or under- test and treat.

#Patients with psychiatric diagnoses or exhibiting psychiatric symptoms or exam findings are indeed vulnerable and especially at high risk of medical error and harm because organic causes for disease can be overlooked and these patients often cannot advocate for themselves and often have poor understanding of their disease/symptoms/medical care.  The solution is not to ignore symptoms like anxiety but instead be a more vigilant care team for that patient in terms of treating their psychiatric symptoms AND appropriately assessing the etiology of that symptom so that you DON’T miss something.

#Lastly, regarding Alyssa, I think that even in retrospect, identifying and treating anxiety may have been completely appropriate.  The error was not in conducting a thorough exam.  The error was bias leading to failure to fully assess (and re-assess) a deteriorating patient and formulate an appropriate assessment and plan.