ArcaMax

DEAR DR. ROACH: I recently had an experience that brought out the desire in me to help educate health care providers in real time. I had an unexplained swelling of just one ankle. My primary care physician is on leave, so I was referred to urgent care. I was seen by a physician assistant. They asked me a series of questions that they read off their computer and ruled out a deep vein thrombosis (DVT). (They said that the likelihood was -2.) They diagnosed me with plantar fasciitis.

A few days later, I had increased swelling in my ankle and some in my calf. I saw an MD, who referred me for an X-ray and gave me a prescription for meloxicam. They instructed me to call back in a week. A few days later, I had dinner with a friend, who's a retired physician and suggested that a vascular ultrasound would be advised. I asked for the ultrasound, and 10 days after my first visit with the PA, I was diagnosed via ultrasound with a DVT.

I'd like to help the PA understand the result of the care they provided so that they can provide better care in the future for the next patient (ordering X-rays and ultrasounds before pronouncing a diagnosis). I'm sure they'd never know the end result of my experience unless I shared it with them. I want to do this in a kind and thoughtful way, but I'm not sure if I'd be stepping outside my boundaries as a patient. -- S.S.

ANSWER: I think it'd be helpful for the PA to get feedback on an incorrect diagnosis. It'd be appropriate if the person who made the incorrect diagnosis was a physician as well, since any kind of health care practitioner can make mistakes.

What went wrong? The PA used a validated questionnaire called the Wells' Criteria for a DVT (a blood clot within a deep vein). You'd get one point for significant swelling of just one calf, but it sounds like your calf wasn't swollen during the first visit. They felt that plantar fasciitis was more likely than a blood clot, and this gave you a score of -2 in the Wells' Criteria, putting your probability of a DVT at 5%. (I disagree with one part of their assessment. Plantar fasciitis, although it can cause foot pain, especially at the heel when taking the first step of the day, doesn't typically cause ankle swelling.)

The mistake, in my opinion, is that they should've told you that a DVT was still possible. They also should've told you that if the swelling worsened (especially if it started to include your calf), you should come back for additional testing. A 5% risk definitely isn't a 0% risk.

Nobody likes to hear that they made a mistake, and every health care provider is concerned to make a mistake that leads a patient to a bad outcome. (Worries about malpractice lawsuits is only one reason for this.) Telling the PA that you didn't have a complication despite the delayed diagnosis and that you're telling them only so they can improve their care will reassure them and hopefully allow them to learn from this experience. (I'd be an act of kindness to say right away that you have no intention of pursuing a lawsuit, if this is true.)

If you're uncomfortable talking to them, you could also talk or write to the supervising clinician at the urgent care facility.

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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu.

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