Man vs Machine (Online symptom checker)

We as physicians and medical providers have a love-hate relationship with the internet. I do really like my patients being more informed and being able to find information regarding their diagnoses. I do however, struggle with my patients coming in and telling me they’ve been “diagnosed” with this or that ailment, which, upon closer examination, actually is a self-diagnosis, perhaps with some assistance from well-meaning friends, TV commercials or Dr. Google.

Sometimes, it may be the correct diagnosis. But sometimes, an assumption about a diagnosis may lead us as clinicians down an incorrect path as we fail to consider the actual symptoms of you – the flesh and blood patient in front of us. We can get distracted by the facts as presented in what we learn in medical school to call the “past medical history.” I’ve always worried about this as a clinician, but now a study is here to tell me whether I should continue to worry or not.

Some people smarter than I reviewed 23 different online symptom checkers diagnoses for 45 standardized written patient scenarios provided to test medical students. The symptom checkers provided the correct diagnosis in 34% of the cases (interestingly, only 24% for emergent diagnoses only). They faired better when utilizing a top 20 possible diagnosis list, scoring the correct diagnosis within the list 58% of the time.
When the symptom checker’s purpose was to triage the symptoms (advise the patient on whether they needed emergent, non-emergent or self care), they actually did a bit better. When the situation was emergent, the symptom checker was correct with triage advice (remember – not necessarily diagnosis) 80% of the time. But the accuracy dropped off with the non-emergent (55% accuracy) and self-care (33% accuracy) scenarios and some of the programs actually always advised emergent care.

Currently, medical providers’ diagnostic accuracy rate appears to be 85-90% (hey, we’re all human!). An interesting comparison would have been to have some real life medical providers review the symptoms to see how we held up. I like to think I’m better than a computer, but can I objectively prove that I can make a diagnosis equally as well?
Also, would we humans be any better without being able to lay hands on our patient and do an actual physical exam? We humans have information the computers do not – medical history, medications, qualifying factors, and the very important physical exam. This makes a difference. As does our role in medicine – I suspect an ER physician vs a primary care physician might have similar capabilities regarding triage (I hope I know when I situation is emergent!), but different results regarding correct diagnosis depending on the nature of the ailment. We have different roles in the medical field and therefore different skill sets regarding diagnosis of common day to day maladies. Please don’t expect the ER doctor to use their brain space to know how to treat run of the mill urinary incontinence, but I would absolutely anticipate he could quickly distinguish between non urgent causes and life threatening ones (spinal compression, severe infection, seizure, etc). And if you have an acute heart attack or stroke, you definitely want their skills at hand as they will be the difference between whether you hug your kids at their next birthday.

All in all, the online symptom checkers appear to be able to give you a top 20 list of possible diagnoses when you input your symptomology. If you are willing to go through the treatment for each of those possible diagnoses in succession, not worry about missed diagnosis and want to save the copay, then the symptom checkers are worthwhile.
For me, I prefer to utilize my time with patients making sure we don’t miss something severe, then focus on the most likely cause of their symptoms. After a thorough history and physical exam, as needed. Take that, Computer!

Study Source: “Evaluation of symptom checkers for self diagnosis and triage: audit study,” BMJ, June 2015
http://www.bmj.com/content/351/bmj.h3480

Screening for breast cancer

Breast cancer is the second most common cancer in women and the leading cause of cancer death in women in the U.S. Those are scary statistics. But you can do something about it. Breast cancer can be caught early and early detection gives you the best opportunity to have treatment that is less invasive and more effective.

Screening for breast cancer is important and you may have heard some mixed messages about it recently. It can get pretty confusing when there are differing opinions.

What we all agree on:
Mammograms save lives. A mammogram is an X-ray of your breasts and is the best way to detect breast cancer in the early stages, when it is easily treatable. These can often be found before you can feel a lump or have any other symptoms.
Getting my boobs squished sucks. Yep, no argument there. If it is severely painful, some women may benefit from topical lidocaine prior to the procedure to make it more tolerable.
Mammograms sometimes detect false positives. Sometimes, in our concern to avoid missing any potential cancerous lesion, we (meaning the computer programs and radiologist) will look at the mammogram and see an area that will look concerning on the first pass. This will result in you returning for further mammogram or ultrasound images and possibly even a biopsy to see if the area is cancerous in nature. Fortunately, often these will be totally normal tests. Unfortunately, these will result in more tests and extra worry on your part until the results come in.

What we still can’t agree on:
When to start mammograms and how often to complete them. Depending on which governing body you ask (USPSTF, NCI, ACOG, AMA, AAFP, ACS, ACR, etc), it can get overwhelmingly confusing to try to figure out when you are supposed to get a mammogram! Some say you should start at age 40, some say age 50, some say stop at age 70, some say age 75. Then they all differ on how often you should get that stressful mashing of the breasts – every year, every 2, every 3 years – what’s a woman to do!
Please talk to your doctor. He may have updated information, will be able to review your personal health risks (see some of them below), and will review the risks and benefits of completing mammography in the different time frames. You don’t have to make the decision alone.

There are some factors that increase your risk for breast cancer. A first degree relative with breast cancer and the age at which that relative was diagnosed can increase your risk, particularly if that relative had a gene that you could have inherited as well (BRCA). While only 5-6% of breast cancers are associated with this genetic mutation, BRCA testing is available if you have a relative who tested positive for this mutation. Even if your relative didn’t have a BRCA gene, it is important to let your doctor know who in your family had breast cancer and at what age.
You may also have a small increased risk of breast cancer through exposure to estrogen. This can be from birth control pills, never having been pregnant, or having your first child after age 30.

Breast thermography
Breast thermal imaging maps the surface heat of the breast using a heat sensitive camera. Unfortunately, breast thermography has not been shown to be an effective screening tool for breast cancer and should not replace mammography. Thermal imaging was first suggested as an alternative based on the observations that breast cancer patients had elevated skin temperatures over their cancers. In the original investigations, thermography was found to have a false negative rate of greater than 60% and a 2012 review showed that it missed 75% of the cancers seen on mammogram. Although the U.S. FDA did approve infrared imaging technology (based on safety data, not efficacy), it did issue a safety communication stating “the FDS is unaware of any valid scientific evidence showing that thermography, when used alone, is effective in screening for breast cancer.” The American Cancer Society recommends “thermography should not be used as a substitute for mammograms.”

Breast cancer is detectable early and treatable early. Please contact your doctor and arrange for a mammogram!

Family Medicine vs Internal Medicine

Family medicine is the medical specialty that provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system and every disease entity.
AAFP. “Family Medicine, Definition of.” http://www.aafp.org/online/en/home/policy/policies/f/fammeddef.html.

First, let’s start with what it takes to become a doctor. After completing an undergraduate degree (usually 4 years), one must go through the 4 fun years of medical school. While each school operates differently, the fundamentals are the same – learn book stuff, learn clinical stuff, see patients.

After medical school is residency (the first year of which is called internship) and this is where the training starts to really differ. Pediatrics residents focus on babies and children, surgical residents focus on surgery, ophthalmology residents focus on eyes, internal medicine residents focus on adults.

Family medicine residents focus on…everything. Family medicine residents learn adult medicine (including ICU), pediatric medicine, gynecology, obstetrics (although many if not most don’t continue to practice after residency) and psychiatric care. There is time devoted to most specialties (cardiology, dermatology, orthopedics, gastroenterology, etc) and more time is spent in an area of interest to that particular resident.

Internal medicine residents also get time devoted to specialties, but don’t have the pediatric or obstetric training that the family medicine residency requires. Internal medicine offers more options to specialize after residency – cardiology, rheumatology, pulmonology, etc. Family medicine is more limited in this manner – geriatrics, sports medicine, obstetrics.

Both family physicians and internists can provide high quality primary care. Importantly, you want a physician who will look at you as a whole person, not a disease or ailment. Remember, your goal is a long term commitment and working relationship. When you’re seeking a medical spouse, a one night stand just won’t do.

Written by M. Mitchell, M.D.

What is primary care?

Simply put, primary care is your entry into medical care. More importantly, primary care is your long term partner in maintaining your optimal health, for better or for worse, in sickness and in health, from this day forward until death do us part – indeed your medical spouse.

Primary care is care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern. Primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, as well as diagnosis and treatment of acute and chronic illnesses.
Primary care physicians devote the majority of their practice to providing primary care services to a defined population of patients. The style of primary care practice is such that the personal primary care physician serves as the entry point for substantially all of the patient’s medical and health care needs – not limited by problem origin, organ system, or diagnosis. Primary care physicians are advocates for the patient in coordinating the use of the entire health care system to benefit the patient.

Source: American Academy of Family Physicians
Primary Care
http://www.aafp.org/about/policies/all/primary-care.html

Primary care physicians (PCPs) are here to help you in many ways. PCPs help you maintain your preventative care so that you can prevent illness or catch it early. PCPs are trained to diagnose – is that cough really something to worry about? PCPs are trained to treat illness, both long term issues like diabetes and acute issues like the flu. PCPs help you navigate the health care system if the medical care you need is beyond primary care capabilities. PCPs coordinate the care you receive from multiple providers if your condition warrants it.

And, if the system works like it should, and you have a primary care provider who knows you and sees you on a regular basis, primary care physicians have many less well-defined job descriptions. Primary care physicians can help you recognize interrelated symptoms that you wouldn’t have felt were connected. PCPs know you, your families, celebrate your successes and mourn your losses. PCPs know your history and health and can recognize more subtle changes than might have otherwise been unapparent.

Finding the right primary care physician can be as difficult as finding the right spouse (why is it so hard to find someone who cooks, cleans, does windows and is independently wealthy?), but equally as important. The right fit could be a life saver.

Written by M. Mitchell, M.D.