Categories of discrepancy between diagnoses according to the underlying disease. Types of discrepancies between diagnoses
Nosology is the study of diseases (from the Greek. nosos- illness and logos- doctrine), which allows solving the main problem of private pathological anatomy and clinical medicine: knowledge of structural-functional relationships in pathology, biological and medical basics diseases. Its content consists of problems without which neither the theory nor the practice of medicine is possible.
Nosology consists of the following doctrines and concepts.
◊ Etiology is the study of the cause of diseases.
◊ Pathogenesis is the study of the mechanisms and dynamics of disease development.
◊ Morphogenesis - morphological changes that occur during the development of diseases.
◊ Clinical and morphological manifestations of diseases, including their complications and outcomes.
◊ The doctrine of nomenclature and classification of diseases.
◊ The theory of diagnosis, i.e. identification of diseases.
◊ Pathomorphosis - the study of the variability of diseases under the influence various factors.
◊ Medical errors and iatrogenics are diseases or pathological processes caused by the actions of medical personnel.
The beginning of nosology was laid by D. Morgagni. In 1761, he wrote a six-volume work, “On the Location and Causes of Diseases Discovered by Dissection,” creating the first scientific classification and nomenclature of diseases. Currently, nosological units are distinguished in accordance with nosology. These are specific diseases with a specific etiology and pathogenesis, a typical clinical picture, consisting of a combination characteristic symptoms and syndromes.
Symptom-a sign of a disease or pathological condition.
Syndrome- a set of symptoms characteristic of a certain disease and related by a single pathogenesis.
Disease- a complex concept that does not have an exhaustive formulation, but all definitions emphasize that illness is life. The concept of disease necessarily implies a disruption in the interaction of the body with the external environment and a change in homeostasis.
Each definition of disease emphasizes only one aspect of this condition. Thus, R. Virchow defined illness as “life under abnormal conditions.” L. Aschoff believed that “a disease is a dysfunction that results in a threat to life.” The Great Medical Encyclopedia gives the following definition: “Disease is a life disrupted in its course by damage to the structure and function of the body under the influence of external and internal factors with reactive mobilization in qualitatively unique forms of its compensatory and adaptive mechanisms; the disease is characterized by a general and particular decrease in adaptability to the environment and restriction of the patient’s freedom of life.” This is a cumbersome, but most complete definition, however, it is largely vague and does not completely exhaust the concept of disease.
In understanding the disease there are provisions of an absolute nature.
◊ Disease, like health, is one of the forms of life.
◊ Disease is a general suffering of the body.
◊ For a disease to occur, a certain combination of external and internal environmental factors is necessary.
◊ In the occurrence and course of the disease vital role belongs to the compensatory and adaptive reactions of the body. They may be sufficient for cure or insufficient, but their participation in the development of the disease is mandatory.
◊ Any disease causes morphological changes in organs and tissues, which is associated with the unity of structure and function.
ETIOLOGY
Etiology (from Greek. aitia- reason, logos- doctrine) - the doctrine of the causes and conditions for the occurrence of diseases. The question of why diseases arise has concerned humanity throughout history, and not only doctors. The problem of cause-and-effect relationships has always occupied philosophers of various directions. The philosophical aspect of the problem is also very important for medicine, since the approach to treating the patient depends on understanding the cause-and-effect relationships. Highest value have theories of causalism (from lat. causalis- causal) and conditionalism (from lat. condicio- condition).
The doctrine of etiology dates back to Democritus (IV century BC) - the founder of causal thinking, who saw the causes of diseases as disturbances in the movement of atoms, and Plato (IV-III centuries BC) - the founder of objective idealism, who explained the causes of phenomena are the relationship between soul and body (the philosophical basis of modern psychosomatics). The beginning of the doctrine of the causes of diseases is the belief in demonic forces that inhabit humans, and the teachings of Hippocrates (IV-III centuries BC) about the causes of diseases as a result of violations of the fundamental principles of nature - water in the form of blood, mucus, yellow and black bile . Most of the teachings about etiology have now lost their significance, but two of them - causalism and conditionalism - are still interesting.
Causalism. Causalists, in particular, the famous pathologist and physiologist C. Bernard (nineteenth century), believed that every disease has a cause, but manifests itself only under certain objective conditions. Since the 70s of the nineteenth century. There was a rapid development of the doctrine of microorganisms, associated primarily with the name of L. Pasteur. This led to the idea that any disease has only one cause - bacteria, and the conditions for the development of the disease are secondary. This is how a type of causalism arose - monocausalism. However, it soon became clear that the presence of a microorganism is not enough for the occurrence of a disease (the concept of bacilli carriage, dormant infection, etc.), that under equal conditions two people react differently to the same microorganism. The study of the reactivity of the body and its influence on the occurrence of the disease began. During the development of the doctrine of reactivity, the idea of allergy appeared. Causalism as a doctrine about the causes of diseases began to lose its supporters.
Conditionalism, which arose against this background, completely denies the causes of diseases and recognizes only the conditions for their occurrence, and only subjective ones, excluding, for example, socio-economic conditions. The founder of conditionalism, the German philosopher M. Verworn (nineteenth-twentieth centuries), believed that the concept of causality must be excluded from scientific thinking and instead introduce abstract representations, as in mathematics. The occurrence of the disease is associated with various conditions. Verworn wrote that a doctor must know three things: the conditions of health in order to maintain them, the conditions for the development of diseases in order to prevent them, and the conditions of recovery in order to use them. Denying this understanding of cause-and-effect relationships in the development of diseases, modern medicine, however, often takes the position of conditionalism, especially when the cause of the disease is unknown, but the conditions for its development are known.
The modern view of the problems of medicine is to understand that a disease occurs when, under the influence of a cause in specific conditions, homeostasis is disrupted, i.e. the balance of the body with the external environment, in other words, when the body’s adaptability to changing factors external environment becomes insufficient. External environment - social, geographic, biological, physical and other environmental factors. Internal environment - conditions that have arisen in the body itself under the influence of hereditary, constitutional and other characteristics. The external and internal environment constitute living conditions.
Thus, from a modern point of view, the concept of etiology is interpreted more broadly - as the doctrine of the complex processes of interaction of the human body with the cause of the disease and the complex of additional conditions necessary for the implementation of this interaction. Hence the main position of modern medicine - there cannot be a disease without a cause, and the cause determines its specificity, i.e. qualitative features of a specific disease
Etiology answers the question about the cause of a particular disease. Many diseases can be caused by external influences environment, as well as disorders that occur in the body itself, for example, genetic defects or birth defects organs. More often, the causes of diseases are environmental factors, depending on many conditions. The etiology of many diseases, for example, most infectious, endocrine diseases or injuries, is known. However, a number of diseases have a still unknown etiology (for example, mental illness, malignant tumors, atherosclerosis, sepsis, sarcoidosis, etc.). Without fully knowing the causes of the disease, it can be successfully treated by influencing the development mechanisms. Thus, the clinical signs, course, complications and outcomes of appendicitis are well known; hundreds of thousands are removed every year around the world. vermiform appendages, however, the etiology of appendicitis has not been established. The causes of diseases affect a person under specific conditions of the internal and external environment; depending on these conditions, some people develop a disease, while others do not. Knowing the causes of the disease greatly facilitates diagnosis and allows etiological treatment, i.e. aimed at eliminating these causes.
PATHOGENESIS
NOMENCLATURE AND CLASSIFICATION OF DISEASES
The most important parts of nosology are medical nomenclature (a list of agreed names of diseases and causes of death) and medical classification (a grouping of nosological units and causes of death to achieve certain goals). Both the classification and the nomenclature are constantly supplemented and modernized as knowledge about the diseases included in the nomenclature changes, or as new diseases appear. The modernization of the nomenclature is carried out by the World Health Organization (WHO), which receives information on diseases and causes of death from all UN member countries. A WHO expert committee analyzes this information and compiles the International Classification of Diseases (ICD), a system of categories reflecting morbidity and causes of death in the population. Periodically, the WHO expert committee holds assemblies and takes into account all changes in the understanding of the etiology and pathogenesis of diseases over 8-10 years, revising existing classification and the nomenclature of diseases, and compiles new ones, taking into account new knowledge and ideas. The compilation of a new nomenclature and classification of diseases is called a revision. Currently, the whole world uses the ICD 10th revision (1993). After drawing up this document, it is translated into the languages of the countries that are members of the UN and introduced as a mandatory guide to action for all medical institutions and medical workers in each country. Medical diagnoses must comply with the ICD, even if the name of the disease or its form does not correspond to national ideas. Unification is necessary in order to global health could have a clear understanding of the medical situation in the world and, if necessary, provide special or humanitarian assistance to countries, develop and implement preventive measures on a regional or continental scale, train qualified medical personnel for different countries. The international classification and nomenclature of diseases reflects the level of medical knowledge of society and determines the directions of research for many diseases.
ICD-10 consists of three volumes.
Volume 1 - special list for statistical development.
Volume 2 - a collection of instructions for using ICD-10.
Volume 3 is an alphabetical index of diseases and injuries by their nature, including the following sections:
∨ an index of diseases, syndromes, pathological conditions and injuries that were the reason for seeking treatment medical care;
∨ pointer external reasons injuries, description of the circumstances of the event (fire, explosion, fall, etc.);
∨ list of medicinal and biological products, chemical substances causing poisoning or other adverse reactions.
The alphabetical index contains basic terms or keywords denoting the name of a disease, injury, syndrome, iatrogenic pathology, subject to special unified coding. For this, there are alphanumeric code numbers containing 25 letters of the Latin alphabet and four-digit codes, where the last digit is placed after the period. Each letter corresponds to up to 100 three-digit numbers. Various medical associations have created additional International classifications for individual medical disciplines (oncology, dermatology, dentistry, psychiatry, etc.) included in the ICD. As additional classifications, they are coded with additional digits (fifths and sixths).
DIAGNOSIS
Diagnosis (from Greek. diagnosis- recognition) - a medical report on the state of health of the subject, on an existing disease (injury) or on the cause of death, expressed in terms provided for accepted classifications and nomenclature of diseases. The diagnosis can be preliminary or final, histological or anatomical, retrospective or forensic, etc. clinical medicine There are clinical and pathological diagnoses. Establishing a diagnosis, i.e. Recognizing a disease is one of the main tasks of a doctor. Depending on the clinical diagnosis, treatment is prescribed; it can be adequate and effective only if the diagnosis is made correctly. But it can be ineffective and even cause fatal consequences for the patient if an incorrect diagnosis is made. Formulating a diagnosis allows you to trace the doctor’s thinking when recognizing and treating a disease, find a diagnostic error and try to understand its cause. A good doctor is, first of all, a good diagnostician.
The pathological diagnosis is no less important. It is formulated by a pathologist after an autopsy of a deceased patient based on the detected morphological changes and medical history data. By comparing clinical and pathological diagnoses, the pathologist establishes their agreement or discrepancy; this reflects the level of diagnostic and therapeutic work of the medical institution and its individual doctors. Detected errors in diagnosis and treatment are discussed at clinical and anatomical conferences of the hospital. Based on the pathological diagnosis, the cause of death of the patient is determined, which allows medical statistics study issues of population mortality and its causes. And this, in turn, contributes to the implementation of government measures aimed at improving the country’s healthcare and developing measures social protection population.
In order to compare clinical and pathological diagnoses, they must be made according to the same principles. The ICD also requires uniformity in the nature and structure of the diagnosis, since the diagnosis is the basic document for all subsequent medical documentation. The fundamental principle of making a diagnosis is the presence of three main headings: the main disease, complications of the main disease, and concomitant diseases.
Main disease usually represents a nosological unit, and the concomitant is a pathological background that contributes to the development of the underlying disease. IN clinical diagnosis underlying disease - a condition that required treatment or examination of the patient at the time of seeking medical help. In a pathological diagnosis, the main disease is a disease that itself or through its complications caused the death of the patient. The cause of death is coded according to the underlying disease in the ICD system.
Complication- a disease pathogenetically related to the underlying disease, aggravating its course and outcome. In this definition, the key concept is “pathogenetically related”; this connection is not always easy to grasp, and without it the disease cannot be a complication. Resuscitation complications are an independent line in the diagnosis. They describe the changes that have arisen due to resuscitation measures, and not the underlying disease, and therefore are not pathogenetically related to it.
The principles of diagnosis formulation are illustrated by the following examples.
Patient I., 80 years old, developed lobar pneumonia, which caused his death. The main disease is lobar pneumonia, and the pathological diagnosis begins with it. This disease arose in an elderly man with reduced reactivity, who, even before the development of pneumonia, suffered from atherosclerosis with predominant damage to the vessels of the heart. Atherosclerosis coronary arteries caused chronic progressive hypoxia, which led to disruption of the metabolism of the heart muscle, the development of diffuse small-focal cardiosclerosis and reduced the functionality of the myocardium. This, in turn, caused compensatory processes in the heart, including hyperfunction of other muscle fibers. Myocardial hyperfunction in combination with hypoxia caused the development of protein and fatty degeneration in cardiomyocytes, which allowed the heart to work in conditions of relative health of the patient. Involutive processes in an elderly person led to the development of pulmonary emphysema, a decrease in the level of gas exchange and, as a result of a combination of these factors, diffuse pneumosclerosis. As long as the person was relatively healthy, changes in the heart and lungs allowed them to function at a life-sustaining level. However, the occurrence of extreme conditions (pneumonia) contributed to a decrease in the respiratory surface of the lungs, increased hypoxia, and the addition of general intoxication of the body, which aggravated fatty degeneration myocardium. At the same time, there was a sharp increase functional loads on the heart and lungs, however, the adaptive and compensatory capabilities of the body are largely exhausted, metabolism and reactivity are reduced. Under these conditions, the heart could not cope with the load, and it stopped.
When formulating a pathological diagnosis, the main disease is lobar pneumonia, since it caused the death of the patient. In this case, it is necessary to indicate the localization, prevalence inflammatory process and stage of the disease. Beginning of the diagnosis: the main disease is left-sided lower lobe lobar pneumonia in the stage of gray hepatization. In the heading “concomitant diseases” it is necessary to indicate atherosclerosis with damage to the vessels of the heart (atherocalcinosis with stenosis of the lumen of the left coronary artery by 60%), diffuse small-focal cardiosclerosis, fatty degeneration of the myocardium, senile pulmonary emphysema, diffuse pneumosclerosis. Thus, the concept of “lobar pneumonia” received a deeper meaning when describing concomitant diseases. Such a diagnosis allows us to understand the cause of death of a given patient.
If the same patient suffering from lower lobar lobar pneumonia develops an abscess in the area of fibrinous inflammation, this will significantly worsen the patient’s condition. As a result of severe intoxication, a sharp decrease in the patient's reactivity and the appearance of abscesses in other lobes of the lung are possible. Putrefactive bacteria can enter the affected lung through the bronchi, causing gangrene of the lung and death of the patient. In this case, in the diagnosis after the main disease - left-sided lower lobar lobar pneumonia there should be a "complications" section, it will indicate multiple abscesses and gangrene of the left lung. Concomitant diseases are the same. A lung abscess is pathogenetically related to the underlying disease; it is its complication.
It is not always possible to describe all the pathology found at an autopsy as one underlying disease. Often several diseases are present and considered to be the underlying disease. To describe such a situation in the diagnosis, there is a heading “combined underlying disease”, which allows you to name several diseases that led to the death of the patient as the main ones. In relation to each other, these diseases are defined as competing or combined.
Competing diseases- two or more diseases, each of which itself or through its complications could lead to death of the patient. This situation can be explained using a situation that often arises.
An elderly patient was hospitalized for stage IV gastric cancer with multiple metastases and tumor disintegration. There is no doubt that the patient is dying and it is no longer possible to help him. The tumor causes a restructuring of many processes in the body, including an increase in blood clotting. At the same time, the patient has severe atherosclerosis of the coronary arteries, against this background thrombosis of the descending branch of the left coronary artery develops, massive heart attack left ventricular myocardium, acute heart failure. The patient died 12 hours after the heart attack. What is considered the main disease that caused the death of the patient? He should have died of cancer, but in this state he still lived and, perhaps, would have lived a few more days. The patient, of course, could have died from a myocardial infarction, but myocardial infarction does not always lead to death. Thus, each of the two diseases could play a fatal role. There is a competition between two deadly diseases. In this case, the underlying disease is combined and consists of two competing diseases. The diagnosis must be written in the following way.
◊ The main combined disease: cancer of the antrum of the stomach with tumor disintegration and multiple metastases to the perigastric lymph nodes, liver, greater omentum, bodies of the V and VII thoracic vertebrae. Cancer cachexia.
◊ Competing disease: infarction of the anterolateral wall of the left ventricle, atherocalcinosis and thrombosis of the descending branch of the left coronary artery.
◊ Complications and comorbidities should then be described.
Often, a patient develops several serious diseases at the same time.
For example, in an 82-year-old patient suffering from widespread atherosclerosis with predominant damage to blood vessels lower limbs, coronary arteries of the heart and arteries of the brain develop atherosclerotic gangrene right foot. He was hospitalized for this. In the clinic, against the background of increasing intoxication with hemolysis of red blood cells, suprahepatic jaundice, and impaired hematopoietic function of the liver, the patient experiences a myocardial infarction. Two days later, against the background of increasing cardiovascular failure, ischemic stroke in the brainstem and the patient dies. What was the main disease that led to death? According to ICD-10, atherosclerosis is not considered as a nosological form; it is only a background for the development of myocardial infarction or cerebrovascular diseases. Each of three diseases could cause the death of the patient. The main disease is combined and includes three competing nosological forms: gangrene of the right foot, left ventricular myocardial infarction and ischemic stroke in the brain stem. The background of all competing diseases is atherosclerosis in the stage of atherocalcinosis with predominant damage to the vessels of the lower extremities, coronary arteries and arteries of the brain. As a complication, one should consider intoxication and its morphological manifestations, as well as edema and swelling of the brain with wedging of its stem part into the foramen magnum. Then they describe concomitant diseases: senile emphysema, gallstones.
Combination diseases- diseases with different etiology and pathogenesis, each of which individually does not cause death, but, coinciding in development time and mutually aggravating each other, they lead to the death of the patient.
An example of combined diseases is a situation where elderly woman fell and broke her hip. For this reason, she went to the hospital, where she underwent osteosynthesis. After this, the patient lay in the ward in a forced position on her back for three weeks. Bilateral focal confluent lower lobe pneumonia developed and the patient died. However, there is no pathogenetic connection between a hip fracture and pneumonia, since pneumonia might not have occurred or it would not have led to death if the patient had undergone breathing exercises, massage, appropriate drug therapy, etc. Congestive pneumonia cannot be considered a complication of a femoral neck fracture. The fracture of the femoral neck itself could hardly have been the cause of death. It is also impossible to assume that these two diseases are unrelated to each other, if only because they arose at the same time, and the body simultaneously responded to injury and pneumonia. A hip fracture as the underlying disease is beyond doubt, since the patient sought medical help for this disease and received treatment. What is pneumonia, which occurred later than the fracture, but had a significant role in the death of the patient? Pneumonia cannot be the main disease; the main disease is a hip fracture. Pneumonia cannot be a competing disease, since a fracture of the femoral neck could hardly cause death. For such situations, there is the concept of a combined underlying disease. In the example, the diagnosis should be written as follows.
◊ Main combined disease: fracture of the left femoral neck, condition after osteosynthesis.
◊ Combined disease: bilateral lower lobe focal confluent pneumonia.
◊ This is followed by the heading “complications”, for example, suppuration of a postoperative wound in the area of the left hip joint or asthmatic syndrome in a patient suffering from bilateral pneumonia.
◊ After complications, concomitant diseases are indicated, for example, atherosclerosis with predominant damage to the heart vessels, chronic ischemic heart disease, etc.
Background disease- a disease that played a significant role in the occurrence and unfavorable course of the underlying disease, the development of fatal complications. It may be included under the heading "underlying disease." The concept of background disease was introduced by decision of the WHO in 1965; at first it was used when formulating the diagnosis of myocardial infarction. Now this section is used for many diseases.
The introduction of the concept of “background disease” has its own history. Until the middle of the last century, myocardial infarction as a complication of atherosclerosis or hypertension was not recorded in WHO statistics, which take into account only the underlying disease. Meanwhile, myocardial infarction has become the leading cause of death in the world. To develop measures for its prevention and treatment, statistics on morbidity and mortality specifically from myocardial infarction were needed. Therefore, in 1965, the WHO Assembly adopted a special resolution: in order to develop measures for the prevention of acute ischemic heart disease, consider myocardial infarction as the main disease and begin writing a diagnosis from it. However, realizing that myocardial infarction is pathogenetically a complication of atherosclerosis and hypertension, we introduced the concept of background diseases and began to consider atherosclerosis and hypertension as such. This principle of writing a diagnosis gradually began to be used when writing a diagnosis of cerebrovascular disorders, since they are also complications of atherosclerosis or hypertension and are associated with stenosis of the cerebral arteries with atherosclerotic plaques. However, atherosclerosis of the arteries occurs not only in these diseases. Diabetes mellitus occurring with severe atherosclerosis, also began to be mentioned in the diagnosis as a background disease. Currently, any diseases that precede the development of the underlying disease and aggravate its course are often considered background.
Polypathies- a group of major diseases, consisting of etiologically and pathogenetically related diseases ("family of diseases") or a random combination of diseases ("association of diseases"). Polypathies may consist of two or more competing, combined and background diseases. In such cases, the direct cause of death is taken as the underlying disease.
Thus, in a clinical and pathoanatomical diagnosis, the heading “main disease” may consist of one nosological form, a combination of competing or combined diseases, a combination of the main and background diseases. In addition, the equivalent of the underlying disease, according to the ICD, may be complications of treatment or errors during medical procedures (iatrogenics).
Cause of death. The pathological diagnosis is completed by the “Conclusion on the cause of death.” It can be initial and immediate.
The initial cause of death is an illness or injury that caused a successive series of disease processes that directly led to death. In the diagnosis, the primary cause of death is the underlying disease, which comes first.
The immediate cause of death occurs as a result of complications of the underlying disease.
Outcome of the disease can be favorable (recovery) or unfavorable (death). A favorable outcome may be complete or incomplete.
A complete favorable outcome - complete recovery, reparation of damaged tissues, restoration of homeostasis, the possibility of returning to normal life and work.
An incomplete favorable outcome is the occurrence of irreversible changes in organs, disability, and the development of compensatory and adaptive processes in the body.
For example, regarding cavernous tuberculosis The patient underwent a lobectomy of the apex of the right lung. There was a cure for cavernous tuberculosis, i.e. The outcome of the disease is generally favorable. However, in the middle lobe of the right lung a rough postoperative scar, in the middle and lower lobes there is compensatory emphysema, and in the place of the former upper lobe there has been a proliferation of connective tissue. This led to deformation of the chest, curvature of the spine and displacement of the heart. Such changes undoubtedly affect the patient’s work prognosis and lifestyle.
DIFFERENCE IN DIAGNOSIS
The pathological diagnosis must be compared with the clinical diagnosis. The autopsy results and diagnosis are usually analyzed together with the attending physician. This is necessary for a final clarification of the etiology, pathogenesis and morphogenesis of the disease in a given patient. Comparison of diagnoses is an important indicator of the quality of work of a medical institution. A large number of coincidences between clinical and pathological diagnoses indicates the good work of the hospital and the high professionalism of its employees. However, there is always some percentage of discrepancies between clinical and pathological diagnoses. Diagnosis can be complicated by the patient’s serious condition or inadequate assessment of his feelings. There may be errors in laboratory research, incorrect interpretation of x-ray data, insufficient experience of the doctor, etc. Discrepancies between clinical and pathological diagnoses are inevitable; we are talking about the number of such discrepancies.
The reasons for the discrepancy between clinical and pathological diagnoses may be objective And subjective.
Objective reasons for diagnostic errors: the short duration of the patient’s stay in the hospital, his severe, including unconscious, state, which does not allow necessary research, the difficulty of diagnosing, for example, a rare disease.
Subjective reasons: insufficient examination of the patient if possible, incorrect interpretation of laboratory and X-ray data due to insufficient professional knowledge, erroneous conclusion of a consultant, incorrect construction of a clinical diagnosis.
The consequences of a diagnostic error and the doctor’s responsibility for this may vary. Depending on the nature, causes and consequences of errors, discrepancies in diagnoses are divided into three categories. Additionally, the discrepancy in the underlying disease, complication of the underlying disease, localization is taken into account pathological process. If there is a discrepancy between the clinical and pathological diagnoses, it is necessary to indicate the reason for the discrepancy.
A 65-year-old patient in an unconscious state was urgently brought to the clinic. Relatives reported that he suffered from hypertension. Available clinical examination, including puncture of the spinal canal and consultation with a neurologist, allowed us to suspect a cerebral hemorrhage. Were held necessary measures in accordance with the diagnosis, however, they were ineffective, and the patient died 18 hours after admission to the intensive care unit. The section revealed lung cancer with metastases to the brain and hemorrhage in the area of metastasis. There is a discrepancy in diagnoses. But doctors cannot be blamed for this, because... they did everything possible to establish the underlying disease. However, due to the serious condition of the patient, doctors were only able to determine the localization of the pathological process that caused clinical symptoms, and tried to save the patient. This is a discrepancy in diagnoses according to the nosological form of category 1. The reasons for the discrepancy are objective: the severity of the patient’s condition and the shortness of his hospital stay.
◊ For example, in the clinic a patient was diagnosed with cancer of the head of the pancreas, and a section revealed cancer of the large duodenal nipple. There is a discrepancy in diagnoses based on the localization of the pathological process. The reason for the discrepancy in diagnoses is objective, since the symptoms for both tumor localizations in the terminal stage of the disease are identical, and the diagnostic error did not affect the outcome of the disease.
◊ Another situation is possible. An 82-year-old patient is admitted to the department with a diagnosis of “Suspected stomach cancer.” Upon admission, she underwent a laboratory examination and an ECG, establishing the presence of chronic ischemic heart disease. X-ray of the stomach provided insufficient evidence for the presence of a tumor. They planned to repeat the study in a few days, but this was not done. However, for some reason there was no doubt about stomach cancer and the patient was not examined further. On the 60th day of her stay in the department, the patient died, she was given a clinical diagnosis: “Cancer of the body of the stomach, metastases to the liver.” The section actually revealed a small cancer, but of the fundus of the stomach, without metastases, and, in addition, an extensive left ventricular myocardial infarction at least three days ago. Consequently, there are competing diseases - gastric cancer and acute myocardial infarction. Failure to recognize one of the competing diseases is a discrepancy in diagnoses, since each of the diseases could cause death. Considering the age and condition of the patient, it was unlikely that radical surgical treatment stomach cancer (gastrectomy, esophageal-intestinal anastomosis). However, the myocardial infarction should have been treated, and the treatment may have been effective, although this cannot be confirmed. An analysis of the medical history showed that the rounds of the attending physician and the head of the department were of a formal nature; no one paid attention to the fact that lab tests and the ECG was not repeated for 40 days. No one noticed that the patient had symptoms of myocardial infarction, so the necessary studies were not carried out, which led to a diagnostic error. This is category 2 of discrepancy between clinical and pathological diagnoses for a competing disease, but the reason for the discrepancy in diagnoses is subjective - insufficient examination of the patient, although all the conditions were there for this. The error is a consequence of the negligent performance of their duties by the doctors of the department.
Category 3 discrepancy in diagnoses - a diagnostic error led to incorrect medical tactics, which had fatal consequences for the patient. This category of discrepancy in diagnoses often borders on medical crime, for which the doctor may be held criminally liable.
For example, a department is treating a patient with a diagnosis of " interstitial pneumonia", but the symptoms of the disease are not entirely typical, the treatment is ineffective. A consultant phthisiatrician is invited. He suspected pulmonary tuberculosis and prescribed a number of diagnostic tests, including tuberculin skin tests, repeated sputum tests, and a tomographic examination of the right lung. However, the attending physician only performed one recommendation: he sent the sputum for analysis, received a negative result and did not examine the sputum further. The doctor did not follow the remaining recommendations, but continued to carry out ineffective treatment. Three weeks after consulting the phthisiatrician, the patient died. In the clinical diagnosis, the main disease was called interstitial pneumonia of the lower and middle lobes of the right lung. The section revealed tuberculous caseous pneumonia of the right lung, which caused severe intoxication and death of the patient. In this case Not correct diagnosis, and without objective reasons led to the wrong, ineffective treatment and death of the patient. If the recommendations of the TB consultant were followed, the diagnosis could be made correctly, the patient could be transferred to a TB clinic, where the special treatment. Thus, this is a discrepancy in diagnoses of the third category, when incorrect clinical diagnosis led to incorrect treatment and fatal outcome of the disease. The cause of the diagnostic error is subjective; it became possible as a result of insufficient examination of the patient and failure to follow the consultant’s recommendations.
Diagnostic errors require comprehensive analysis so that they are not repeated. For such an analysis, clinical and anatomical conferences are needed, which should be held in each hospital once a quarter in the presence of the chief physician and the head of the pathology department. All hospital doctors participate in the conferences. Cases of discrepancies between clinical and pathological diagnoses are discussed, and clinicians and pathologists report. In addition, they must appoint an opponent - one of the most experienced doctors at the hospital who had nothing to do with the case under consideration. A general discussion helps to reveal the reasons for the diagnostic error; if necessary, the hospital administration takes appropriate measures. In addition to diagnostic and treatment errors, rare cases are discussed at clinical and anatomical conferences, especially if they were correctly diagnosed. Clinical anatomical conferences are a necessary professional school for all hospital doctors.
IATROGENICS
Iatrogenesis - diseases or complications of diseases associated with the actions of medical personnel. In the diagnosis they are included in the heading “main disease”. Iatrogenesis (from Greek. iatros- doctor and genes- arising, damaged) - any adverse consequences of preventive, diagnostic, therapeutic interventions or procedures that led to dysfunction of the body, disability or death of the patient. Iatrogenesis associated with the actions of doctors can be classified as medical errors and medical misconduct, or crimes.
Medical error- conscientious error of the doctor in the performance of his professional duties, it cannot be foreseen and prevented by this doctor. Medical error is not associated with the doctor’s careless attitude to his duties, ignorance or malicious action. Medical error is, in most cases, a consequence of insufficient professional experience, lack of necessary laboratory or instrumental capabilities for correct diagnosis and treatment.
Medical misconduct occurs when, having every opportunity to foresee and prevent the consequences of a disease or injury and provide assistance to the patient, a doctor, due to neglect of his professional duties or for selfish reasons, carries out treatment that leads to a serious, sometimes fatal outcome of the disease. The fact of a medical crime or misdemeanor can only be established by a court.
Iatrogenesis can be the result of tactical or technical errors by the doctor.
Tactical mistakes: incorrect choice research methods due to underestimation of the degree of risk of manipulation (patient’s age, medical history, individual reaction to manipulation), incorrect choice of indications for surgical intervention or administration of medications, preventive vaccinations and so on.
PATOMORPHOSIS
Pathomorphosis (from Greek. pathos- illness and morphosis- formation) - persistent change in clinical and morphological manifestations diseases under the influence of environmental factors. Knowledge and understanding of pathomorphosis is important, since a change in the picture of the disease leads to a change in its diagnosis, treatment and prevention. This requires the development of new diagnostic methods and medications, in turn, affecting pathogens. The result may be a change in the epidemiology of the disease and, consequently, a change in epidemiological and preventive activities carried out throughout the health care system.
Pathomorphosis can be true or false.
True pathomorphosis They are divided into general (natural), consisting in a change in the general panorama of diseases, and private, reflecting changes in a specific disease.
General pathomorphosis is associated with the evolution of the external world, including changes in pathogens, their interaction with humans and animals, the emergence of new pathogens, new factors affecting humans (radiation, accumulation of various chemicals in the atmosphere, etc.). This changes the overall landscape of diseases. So, in the 19th century. The epidemiological picture in the world was characterized by bacterial infections, in the 20th century - cardiovascular and oncological diseases, in the 21st century. promises to be a century viral infections. However, the natural general pathomorphosis occurs over the course of centuries and is therefore little noticeable.
Partial pathomorphosis can be natural (spontaneous) and induced (therapeutic).
◊ Spontaneous partial pathomorphosis is a consequence of changes in the external causes of the development of the disease, which are not always known. For example, it is not known when and why cholera occurs, or why Asiatic cholera, which devastated the globe for hundreds of years, was replaced by cholera caused by Vibrio El Tor, which is less catastrophic. Partial spontaneous pathomorphosis may be a consequence of a change in the human constitution, i.e. internal causes of illness. It reflects the same patterns as the general pathomorphosis, but in relation to a specific disease.
◊ Induced (therapeutic) pathomorphosis is of much greater importance in everyday life. This is an artificially induced change in a specific disease using various measures or certain drug therapy. Thus, long-term anti-tuberculosis vaccination of children immediately after birth led to a shift in the incidence of tuberculosis from the age of 4-5 years to the age of 13-14 years, i.e. to the period when the formation is almost complete immune system, and tuberculosis lost its fatal significance. In addition, acute tuberculous sepsis and tuberculous meningitis. A wide arsenal of specific drugs sharply reduced mortality from acute forms of the disease, the life expectancy of patients increased noticeably, but chronic forms of tuberculosis began to predominate. It was possible to reduce the number of massive pulmonary hemorrhages, but they occur more often cirrhotic forms tuberculosis with the development of pulmonary heart failure and amyloidosis. Under the influence of preventive measures, there has been a change in the epidemiology and symptoms of many childhood infections, etc. Thus, artificial pathomorphosis is a reflection of the successes of preventive and clinical medicine.
◊ However, the experience of our country, which suffered a decline in the socio-economic standard of living of the population, the collapse pharmaceutical industry, a sharp decline in healthcare capabilities, including the sanitary-epidemiological service, the cessation of preventive vaccinations of children and other difficulties showed that if the induced pathomorphosis is not constantly maintained, it disappears. For example, the destruction of the country's anti-tuberculosis service led to the return of tuberculosis to its epidemiology and clinical picture characteristic of the beginning of the twentieth century. as a result, it approached indicators indicating an epidemic of the disease.
False pathomorphosis- apparent change in the disease. For example, among the diseases of young children, rubella and congenital deafness are known. However, as knowledge about the infection deepened, it became clear that deafness is not an independent disease, but a complication of rubella contracted by the fetus during the prenatal period. At early diagnosis and treatment for rubella, congenital deafness disappeared. The disappearance of congenital deafness as an independent disease is a false pathomorphosis.
Thus, the basic principles of nosology make it possible to understand the patterns of disease development, which is the key to their successful diagnosis and treatment. Nosology forces the use of international rules necessary for the interaction of the international medical community.
Comparison of clinical and pathological diagnoses is one of the forms of monitoring the quality of diagnostic and therapeutic work, important way impact on the organization of medical care, the possibility constant increase qualifications of doctors.
1. The comparison is carried out according to three headings, which must contain the final clinical and final pathological diagnoses: a) the underlying disease; b) complications; c) concomitant diseases. The comparison is based on the nosological principle.
The underlying disease (“initial cause of death” according to ICD-10) is an illness or injury that caused a chain of disease processes that directly led to death.
Complications are pathological processes and syndromes that are pathogenetically related to the underlying disease, significantly aggravating the course of the disease and contributing to death.
A concomitant disease is a nosological unit, syndrome, etiologically and pathogenetically not related to the main disease, which does not affect its course.
Clinical and pathoanatomical diagnoses must reflect the etiology and pathogenesis of the disease, a logical temporal sequence of changes, and intranosological characteristics (type of course, degree of activity, stage). When formulating, use modern terms and classification schemes, and coding is carried out in accordance with the headings of ICD-10. The timing of the clinical diagnosis is reflected on the title page and in the epicrisis of the medical history. The diagnosis should be as complete as possible and include the entire complex pathological changes, including those caused by medical influences, should not be a formal diagnosis, but a “diagnosis of a specific patient.”
2. The main clinical and pathological diagnoses may include one or more nosological entities. In the latter case, the diagnosis is called combined and when formulated, the following are distinguished:
Competing diseases - two or more diseases, each of which by itself could lead to death;
Combined diseases are not fatal in themselves, but in combination, developing simultaneously, aggravating the course of the disease and leading to death;
Background diseases are nosological units that played a significant role in the occurrence and unfavorable course of the underlying disease and contributed to the occurrence of severe, sometimes fatal, complications.
3. In accordance with the requirements of the ICD and others regulatory documents Individual syndromes and complications may be presented as the underlying disease in the diagnosis. We are talking mainly about cerebrovascular disease (CVD) and coronary disease heart disease (CHD) due to their special frequency and social significance as the most important reason disability and mortality of the population (at the same time hypertonic disease and atherosclerosis should not disappear from the diagnosis). The above also applies to cases of iatrogenic category III.
4. A comparison of clinical and pathological diagnoses, as a rule, regardless of the length of stay in a medical facility, must be carried out jointly by the pathologist and the attending physician, for which the presence of the latter at the autopsy is mandatory. The result of comparing diagnoses should be a statement of the following facts:
The main clinical and pathological diagnoses coincide or do not coincide. If there is a discrepancy, there is a discrepancy in diagnoses for the underlying disease;
Diagnoses in the headings “background diseases”, “complications” and “concomitant diseases” coincide or do not coincide. There are discrepancies in diagnoses across these headings.
The discrepancies section for the underlying disease includes the following options:
1) Divergence of diagnoses according to the nosological principle, according to the etiology of the process, according to the localization of the lesion (including in the absence of indications in the clinical diagnosis of the topic of the process).
2) Failure to recognize one of the diseases included in the combined diagnosis.
3) Substitution of a nosological form with a syndrome or complication (except for CVD and IHD).
4) Incorrect clinical diagnosis (failure to comply with the etiopathogenetic principle, lack of rubrication, assessment of a complication as the main disease or the main disease as a concomitant process).
5) Failure to recognize iatrogenic category III during life. The results of comparison of diagnoses are entered by the pathologist into the clinical-pathological epicrisis, brought to the attention of the attending physician and discussed collectively at meetings of the clinical-anatomical conference, medical commission and study commissions deaths(KILI).
5. Having established the fact of discrepancy in diagnoses for the underlying disease, the category of discrepancy should be determined.
Category I includes cases in which the disease was not recognized at the previous stages, and in this medical facility, establishing a correct diagnosis was impossible due to the severity of the patient’s condition, the short duration of the patient’s stay in this institution and other objective difficulties.
Category II includes cases in which the disease was not recognized in a given institution due to deficiencies in the examination of the patient; It should be borne in mind that correct diagnosis would not necessarily have a decisive influence on the outcome of the disease. However, the correct diagnosis could and should have been made.
Only categories II and III of discrepancies between clinical and pathological diagnoses are directly related to the health care facility where the patient died. Category I of discrepancy between diagnoses refers to those healthcare facilities that provided medical care to the patient in the earlier stages of his illness and before hospitalization in the healthcare facility in which the patient died. The discussion of this group of discrepancies in diagnoses should either be transferred to these institutions, or the medical staff of the latter should be present at the conference in the health care facility where the patient died.
After comparing the main diagnoses, a comparison is made of the most important complications and concomitant diseases. If the most important complications are not diagnosed, the case should be interpreted precisely as a discrepancy in diagnoses in this section, and not as a statement unrecognized complication when the diagnosis of the underlying disease coincides.
6. The time factor is of no small importance in assessing the level of diagnosis. Therefore, it is advisable, along with comparing diagnoses, to clarify whether the main clinical diagnosis was timely or not, whether complications were diagnosed in a timely manner or late, and whether delayed diagnosis affected the outcome of the disease. A short-term stay of a patient in a hospital is conventionally considered to be less than 24 hours (for urgent patients, the period is reduced and individualized).
7. Determining the category of discrepancy between clinical and pathological diagnoses must necessarily be accompanied by identifying the reasons for the discrepancy, often - defects in the work of the attending physician.
The reasons for discrepancies in diagnoses are divided into 2 large groups: objective and subjective. Objective reasons include cases where it was impossible to establish a diagnosis (short-term stay of the patient in the hospital, severity of his condition, atypical course of the disease, etc.). Subjective reasons include defects in the examination of the patient, insufficient experience of the doctor, incorrect assessment of the results of laboratory and other studies.
8. The final judgment on the category of discrepancy between clinical and pathological diagnoses and its causes belongs to the CILI and the medical commission. In this case, the diagnosis of not only the clinician, but also the pathologist is discussed, because objective and subjective errors diagnostics can also be made during pathomorphological examination. In this case, the reasons for objective errors include the impossibility of conducting a complete detailed autopsy, the inability to carry out the required volume of microscopic examination of sectional material and other analyzes - bacteriological, biochemical, etc. Subjective reasons for errors include insufficient qualifications of the prosector, incorrect interpretation morphological features, technically illiterate or incomplete autopsy, lack of necessary additional research(microscopic, bacteriological, virological, biochemical) in conditions where they are available for implementation. This also includes underestimation of clinical data, reluctance to consult with more experienced specialist, the desire to “fit” the pathological diagnosis to the clinical one.
In controversial situations, when the opinions of clinicians and pathologists do not coincide, and after analyzing the case at the medical commission, the point of view of the pathologists is officially accepted. For further discussion, materials can be transferred to the main and leading specialists of the relevant profile.
The concepts of “coincidence” or “divergence” of clinical and pathological diagnoses are applicable only for comparison (comparison) of the headings “Main disease” (initial cause of death).
Comparison of diagnoses according to other headings, in particular, according to complications, according to
fatal complication (immediate cause of death), the main concomitant diseases is carried out separately and if there is a discrepancy, it is not recorded as a discrepancy in diagnoses, but is indicated additionally, for example, in a clinical-anatomical epicrisis: the diagnoses coincided, but the fatal complication (or concomitant disease) was not recognized.
When comparing diagnoses, only the final clinical diagnosis is taken into account, which is placed on the back of the title page of the medical history, or is indicated as final in outpatient card deceased. Uncategorized clinical diagnoses or with a question mark do not allow their comparison with the pathological diagnosis, which is considered as a discrepancy between diagnoses in category II (subjective reasons - incorrect formulation or execution of the clinical diagnosis).
When deciding whether diagnoses coincide or diverge, all nosological units indicated as part of the underlying disease are compared. In case of a combined underlying disease, undiagnosed any of the competing, combined, background diseases, as well as their overdiagnosis, constitute a discrepancy in diagnoses. In a pathoanatomical diagnosis, compared to a clinical one, the order of competing or combined diseases may change (the one that was in first place will move to second and vice versa). This should be avoided and in cases of coincidence of diagnoses, the order adopted in the final clinical diagnosis should be retained. However, if there is a convincing objective reason for changing the order of nosological forms in the diagnosis, but all nosological units included in the combined underlying disease coincide, a coincidence of diagnoses is set, and the reason for the change in the structure of the diagnosis is justified in the clinical-anatomical epicrisis.
A discrepancy in diagnoses is considered to be a discrepancy between any nosological unit from the heading of the underlying disease in its essence (the presence in the pathological diagnosis of another nosology - underdiagnosis, or the absence of this nosology - overdiagnosis), in localization (including in organs such as the stomach, intestines, lungs, head brain, uterus and its cervix, kidneys, pancreas, heart, etc.), by etiology, by the nature of the pathological process (for example, by the nature of the stroke - ischemic infarction or intracerebral hemorrhage), as well as cases of late (untimely) diagnosis. The fact of late (untimely) diagnosis is established collegiately, during a clinical expert commission.
If there is a discrepancy between diagnoses, indicate the category of discrepancy (category of diagnostic error) and the reason for the discrepancy (one of the groups of objective and subjective).
Categories of discrepancy between diagnoses indicate both the objective possibility or impossibility of correct intravital diagnostics, and on the significance of diagnostic error for the outcome of the disease.
I category discrepancies in diagnoses – in this medical institution, a correct diagnosis was impossible, and a diagnostic error (often made during the patient’s previous requests for medical help) no longer affected the outcome of the disease in this medical institution. The reasons for the discrepancy between diagnoses in category I are always objective.
II category discrepancies in diagnoses – in this medical institution, a correct diagnosis was possible, but a diagnostic error that arose for subjective reasons did not significantly affect the outcome of the disease.
Thus, discrepancies in diagnoses in category II are always a consequence of subjective reasons.
III category discrepancies in diagnoses - in this medical institution, a correct diagnosis was possible, and a diagnostic error resulted in erroneous medical tactics, i.e. led to insufficient (incomplete) or incorrect treatment, which played a decisive role in the fatal outcome of the disease.
The reasons for the discrepancy between diagnoses in category III are always subjective.
Cases of discrepancies in diagnoses, in particular in category III, should not be equated with iatrogenics.
Objective reasons for discrepancies in diagnoses include the following:
1. The short duration of a patient's stay in a medical institution (brevity of stay). For most diseases, the standard diagnostic period is 3 days, but for acute diseases, requiring emergency, emergency, intensive care, including cases of urgent surgery, this period is individual and can be equal to several hours.
2. Difficulty in diagnosing the disease. The entire range of available diagnostic methods was used, but the atypicality, blurred manifestations of the disease and the rarity of this disease did not allow us to make a correct diagnosis.
3. The severity of the patient's condition. Diagnostic procedures were completely or partially impossible, since their implementation could worsen the patient’s condition (there were objective contraindications).
Subjective reasons for discrepancies in diagnoses include the following:
1. Insufficient examination of the patient.
2. Underestimation of anamnestic data.
3. Underestimation of clinical data.
4. Incorrect interpretation (underestimation or overestimation) of laboratory, radiological and other data additional methods research.
5. Underestimation or overestimation of the consultant’s conclusion.
6. Incorrect construction or execution of the final clinical diagnosis.
7. Other reasons.
Only one should be specified main reason discrepancies in diagnoses, since a conclusion containing several reasons simultaneously (a combination of objective and subjective reasons) makes subsequent statistical analysis extremely difficult.
Questions for control and repetition
1. Define such concepts as etiology, pathogenesis, nosology, syndrome, nosological unit.
2. What is the structure of clinical and pathological diagnoses.
3. Define the underlying disease.
4. How do you understand the term competing diseases and combined diseases, what category of diagnosis do they belong to?
5. What is a complication of the underlying disease.
6. Should complications of resuscitation and intensive care be indicated in the final clinical and pathological diagnosis?
7. How do you understand the term “iatrogenic diseases”.
8. List the types of iatrogenies and their place in the structure of the final clinical and pathoanatomical diagnoses.
9. Describe the goals of clinical and anatomical analysis carried out in medical institutions.
11. Name the “uniterm” for accounting for nosological units.
Literature
Paltsev, M. A. Guide to the biopsy-sectional course / M. A. Paltsev, V. L. Kovalenko, N. M. Anichkov. - M.: Medicine, 2004. – 256 p. – (Educational literature for students of medical universities).
Paltsev, M. A. Human pathology. In 3 volumes / M. A. Paltsev, N. M. Anichkov, P. F. Litvitsky. - M.: Medicine, 2007. – (Educational literature for students of medical universities).
Rykov, V. A. Pathologist's Handbook. - Rostov n/d: Phoenix, 2004.- 256 p.
Guide private pathology person. In 2 volumes / ed. N. K. Khitrova, D. S. Sarkisova, M. A. Paltseva. - M.: Medicine, 2005.
Sarkisov, D.S. About some trends in modern stage development general pathology/ D.S. Sarkisov // Arch. Pat. - 1996. - No. 3. – P. 3-7.
Thematic table of contents (For life)
previous on topic………………………………… next on topic
previous on other topics………… next on other topics
I took my cell phone. The interlocutor's voice was lifeless and slow, like that of a person who had accepted defeat.
Hello, professor, it’s the head physician of the hospital *** who is bothering you. I must inform you that our plans for working together it won’t come true - we are finalizing it until the end of the year and closing.
- Why, my dear? It seemed like everything was fine, even the ministry should have finally given a tomograph to neurology the other day?
- I was there. They told me off. They said that we were not working well and were closing us. So this evening we have a staff meeting.
- How is it that you work poorly?
- A large proportion of discrepancies in diagnoses.
- What?
- This is their new fashion. They began to write that our doctors have a 30% discrepancy in diagnoses, which means that they themselves killed 30% of their patients. Now everyone in the ministry is running around, yelling, demanding a reduction. They raised our reporting... and now they’re closing it...
- But, my dear, those 30% who like to quote are from a report at a conference on the organization of healthcare, where it was said that 30% are discrepancies not just between diagnoses, but between diagnoses and post-mortem diagnoses. And they clearly said that these 30% are the world average, and they are often explained by the fact that clinicians write diagnoses based on symptoms, and pathologists write diagnoses based on the cause of death. For example, if they call for an overdose on a drug addict, then the ambulance will write “acute heart failure” in the cause of death, since it cannot write anything else without tests.
- I know, but have you tried to explain this to “them”?
- Yeah, that means they came up with a new magical indicator and now they are fighting for it... So, my dear, go immediately to the ministry, and sign there a protocol of intent stating that you undertake to have in the hospital, starting from the moment the tomograph is installed there, the percentage of discrepancies between the main diagnoses no higher than 5%, otherwise you don’t mind immediate closure without protests and compensation...
- Professor - Are you out of your mind?
- Then I’ll explain, time is precious, we need to be in time before the previous decision is formalized by order. And I’ll go to the hospital for a meeting with you. Just don’t forget that the agreement is in writing, and that there are discrepancies in the main diagnoses. And don’t worry about 5% - you won’t get even that...
=================
Two hours later, I sat at a meeting of the labor collective and listened with interest as the chief accountant, personnel officer and lawyer told the doctors in three voices that they would be closed for bad job doctors, that a fool would make a correct diagnosis of a stroke patient with a tomograph, but if you are a good doctor, you should just make a diagnosis, and correct treatment to determine... Finally, my mobile phone started ringing, the head doctor reported that he had done everything exactly, and I took the floor.
Dear colleagues! According to my joint plan with the chief physician, he just signed a document at the ministry that we, that is, you, will be immediately closed if your main diagnoses differ by more than 5%. And if it is less, then, accordingly, they will not close...
There was silence in the hall. I continued.
So – what is the reason for the high frequency of discrepancies between the main diagnoses? As you understand, this is a formal indicator, so the fewer main diagnoses you use, the better. I propose to leave three diagnoses...
- How to treat? – came a question from the audience.
- To avoid problems with insurance companies, we treat not only the main diagnosis, but also related ones...
- This is a type of “ankle sprain, complicated acute disorder cerebral circulation and a broken arm"? – someone in the hall guessed.
- Exactly!
- How to make the main diagnoses? Without a tomograph, with our frail laboratory facilities?
- And we make the main diagnosis based on the length of the surname. If the surname consists of 4, 7, 10, 13 and so on letters, then we make diagnosis No. 1. If 5, 8, 11, 14 and so on - then number two. And if the number of letters in the surname is divisible by three, then we make a third diagnosis.
There was slight movement in the right wing of the hall, where the staff of the psychiatric department were sitting. The orderlies began to get up, but the doctor, who knew me, calmed them down. I continued.
This way, we won't have any discrepancies within the hospital. And in order to avoid discrepancies with other institutions, these diagnoses must meet the following criteria:
1. They can be given or not given to any person, regardless of his condition,
2. It does not require any laboratory or instrumental studies,
3. The presence of this diagnosis does not require any special treatment,
4. It is impossible to find out whether a cure has occurred or not.
Thanks to this, discrepancies between the main diagnosis and those that will be made outside the hospital walls are impossible in principle.
There was a stir in the hall. The therapists tried to explain something to the surgeons, the anesthesiologists went into their normal state, that is, they calmed down, relaxed and fell asleep, the ultrasound doctor giggled, the junior medical staff took out cosmetic bags and began to preen themselves, and the head. The ENT department began to concentrate on picking his nose. Apparently this method of collecting his thoughts was the most effective, for he stood up and asked:
What are these three magical diagnoses that can be given to anyone just like that and cannot be refuted?
- Sorry, colleagues, I forgot. So, starting today, the hospital makes only the following three diagnoses: dysbiosis, depression and vegetative-vascular dystonia.
Dedicated to the True Teacher of Truth.
