She works at a muffler and brake repair shop. She enters work orders and reports in the computer and she stocks inventory, sometimes up to 10 hours a day. She is 45 years old, is obese and has diabetes. Over the course of several months, she noticed numbness in both her hands, she had difficulty gripping objects and she had plenty of discomfort. This impeded her typing and her stacking of parts.
The doctor took a medical history. While at the clinic, Hazel underwent an electromyography for possible muscle weakness and a nerve conduction study to look for nerve dysfunction. The doctor diagnosed Hazel's problem as carpal tunnel syndrome (CTS). In a few weeks, she had bilateral carpal tunnel release surgery.
But the tests had arrived at false positives. A correct diagnosis would have been tendonitis or myofacial pain. But even if Hazel had CTS, a better solution would have been ergonomic improvements and helping her control her diabetes. All that would not have assured elimination of symptoms, but the CTS release surgery didn't either.
Medical care for injured workers is plagued with high error rates, which for the most part we've tried to ignore. Confronting them gives rise to cognitive dissonance as we seek to simplify relationships with thousands of medical providers.
I defy anyone to cross the street while trying to reconcile the goal of error reduction with the goal of getting doctors to agree to fee discounts.
THREE KINDS OF ERRORS
There are three kinds of medical errors that haunt us. First, diagnosis and treatment is often wrong, as in Hazel's case. Second, providers often fail to accurately assess work factors of impairment and recovery, a factor that is also present in Hazel's case. Third, providers often fail to fully address comorbidities.
These medical errors are so pervasive that I estimate that less than 5 percent, and probably closer to 2 percent, of physicians can consistently avoid these three types of errors in treating injured workers. I derived this estimate by studying provider network recruitment by some resolute insurers.
Adam Seidner, the medical director of Travelers, told me he is determined to reduce the error rate among wrist and hand disorders.
He sees a very high rate--about 40 percent--of faulty diagnostic tests for CTS. The problem is not the technology but inadequate tester training. He said that he is reducing errors with a diagnostic provider network.
He also wants to better balance surgical treatment with more conservative methods of treating CTS. Seidner cited a program in Cincinnati that reduced surgical rates from 40 percent to 5 percent for CTS cases.
None of this is easy to do, in part because there is no such thing as a zero-defect rate in medical decision-making.
A hand surgeon who has worked with about 10,000 wrist and hand work injury patients tells me that the definitive factor in diagnosis for CTS is the patient's history because testing can be so error-prone.
What we want are indisputable standards for diagnostic tests and for treatment planning but what we need is the attention of the right physician.
PETER ROUSMANIERE is an expert on the workers' compensation industry.
June 1, 2010
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