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Diagnosing a Problem

WHEN DOCTORS SEE PATIENTS WITH symptoms such as a rash or a cough, they must be able to quickly ascertain whether the underlying cause is a highly contagious and deadly illness, such as smallpox. A misdiagnosis could pose a threat to the community.

Is the medical community up to the challenge? Not according to a recent study released by The Johns Hopkins University.

In the study, published in the Archives of Internal Medicine, 631 physicians at 30 internal medical residency programs were shown cases of plague. Only 16 percent were able to identify the disease.

The doctors fared somewhat better in diagnosing other diseases, with 49.6 percent giving a correct diagnosis of botulism; for smallpox, 50.7 percent got it right; with anthrax, 70.5 percent. The ability of physicians to manage the diseases was even worse, however, with an overall average of only 25 percent correctly mitigating the risk.

Numbers like that don’t bode well for public health.

But there is good news, says Stephen D. Sisson, M.D., coauthor of the study. After the initial testing, doctors were given an online course in recognizing and managing the four agents. They were then retested after taking the course, and 79 percent correctly diagnosed the diseases and were able to correctly manage them.

Although most doctors are taught about infectious diseases during their medical education, the Johns Hopkins study underscores a need for continuing education. Sisson says the most effective continuing education happens annually or every other year.

While practitioners may acknowledge the need for continuing education on this subject, few states require infectious disease education as part of their licensing procedure. Doctors in Florida, for example, are required to take 40 hours of continuing education courses every two years in order to obtain a license to practice in the state, but infectious disease is not a required course.

Four hours are required in general medical education, and the subjects of the remaining 36 hours are at the discretion of the physician. While the courses must be certified by the American Medical Association (AMA), physicians can take whatever best fits their specialty, which sometimes means infectious disease courses take a backseat.

“We as a profession need to acknowledge our responsibility in this area, and professional societies need to continue to stress this message,” says Sisson. While Sisson does not specifically advocate requiring doctors to take infectious disease courses as part of their board certification or licensing requirements, he does agree that it’s one of the potential solutions to the problem.

Some professional organizations are taking an active role in addressing the issue. The Greater New York Hospital Association offers training sessions to their members on a variety of topics, including infectious diseases and radiological exposure. “We consider our hospital staff as first responders…. We believe that education of our staff is very important,” says Doris Varlese, associate general counsel for the association.

The AMA offers courses that teach doctors to respond to potential biological attacks. But the AMA method does not focus on diagnosing specific diseases. Instead, its focus is on how to properly respond when suspicious diseases are present.

“We’re more concerned with giving physicians the basic information that gives them a commonality—

a ground floor—and hopefully we give him the pieces, such as how do you interact with the public health system, how do you initiate an epidemiological investigation, what’s the federal and state role?” says Dr. James J. James, director of the AMA Center for Public Health Preparedness and Disaster Response.

Although the medical profession has made some strides in recent years, the Hopkins study illustrates the need for much better education about infectious diseases. “As far as an early warning system, I think that physicians, both practicing internists and emergency room physicians, are going to be among the first-line early warning systems,” Sisson says. Training these physicians to recognize potential threats is imperative.