Could Tito-Sen's doc have been wrong?

Despite Jesse Robredo’s tragic death, his spirit lives on in Filipinos’ hearts. Exemplary governance marked his stints as mayor of Naga City, League of Cities president, and Secretary of Interior and Local Governments. He received 14 major awards for government service.

Foremost of these is the Ramon Magsaysay Award (reputed as Asia’s version of the Nobel Prize), in 2000. Earlier, the Konrad Adenauer Medal of Excellence in 1998, the Philippine Jaycees’ Ten Outstanding Young Men in 1990, and the Jaycees International’s Ten Outstanding Young Persons of the World in 1994. Jesse was the very first recipient of the Dangal ng Bayan, the highest award for Filipino public servants, from the Civil Service Commission, Ombudsman and Office of the President, in 1992.

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I could relate with Sen. Tito Sotto’s anguish over losing his infant boy in 1975. I almost lost my only baby, and my wife too during her difficult pregnancy. Fortunately, baby hanged on to dear life inside mama’s womb, and was delivered normally. She’s now a doctor; still the trauma deterred us from our plan for two offspring. Tito-Sen’s ordeal was worse. Infant Vincent Paul woefully had to be incubated bereft of parental caress throughout all of five months of life. Although it has been 37 long years since, Tito-Sen openly wept recounting the pain, during his turno en contra last week against the Reproductive Health bill.

Tito-Sen said his wife Helen was then on pills but still conceived. Complications, premature birth, and demise of Vincent Paul, their doctor blamed on the contraceptive, Diane. All the time a doctor had overseen Helen’s medicating. Helen, an educated woman, had read up on and followed the prescription.

Yet, there’s room for doubt about causes of surprise pregnancies, problems, and fatalities. Thirty-seven years ago, medical science was not as advanced as today. Formulations were less potent, lab tests less clear-cut. Doctors used only available knowledge, technology, and equipment.

Tito-Sen and Helen’s doc might have been precise back then about the cause of death. Then again, the doc also could have been wrong.

Given its high odds, misdiagnosis could have occurred. The malady is prevalent worldwide, though largely unstudied in the Philippines. This, according to Dr. Leonardo Leonidas, just retired clinical professor in pediatrics at the Tufts University School of Medicine, Boston. Misdiagnosis can mislead the doctor and patient. Worse, it can result in “adverse event,” or injury to patient by a medical intervention rather than the underlying medical condition.

In a recent talk at the Philippine Children’s Medical Center in QC, Leonidas gave snapshots of the troubling incidence, courtesy of colleague Dr. Mark Graber:

• In a 1991 Harvard medical practice study of 30,195 hospital records, diagnostic errors accounted for 17 percent of adverse events.

• In a 2000 survey of 15,000 patient records in Colorado and Utah, misdiagnoses led to 6.9 percent of adverse events.

• Same methodology in a 2004 Canadian review, 10.5 percent of adverse events stemmed from incorrect diagnoses.

• In a 1999 Australian inquiry of 2,351 adverse events related to hospitalizations, 20 percent arose from delays in diagnosis or treatment, and 15.8 percent from failure to “synthesize/decide/act” on information.

• In a 2003 New Zealand research of 6,579 inpatient records, diagnostic errors accounted for eight percent of adverse events, of which 11.4 percent were preventable.

Leonidas could find no study of misdiagnoses in the Philippines, save for the rare eye disease of retinoblastoma. Here the misdiagnosis rate was eight percent, better than the ten percent in advanced countries.

What causes misdiagnoses? As with any field, medicine is prone to Murphy’s Law: if anything can go wrong, it will. The Archives of Internal Medicine (Journal of the American Medical Association) in July 2005 traced two-thirds of misdiagnoses to system, and one-third to cognitive errors.

System errors include communication and coordination breakdown, unavailable expertise when needed, inaccessible records and test results for review, gaps in testing and alerting, and poor supervision of trainees. Leonidas cited a study of radiology missing 10-13 percent of breast cancers, and pathology misreading up to two percent of cancers.

Cognitive errors are the doctors’, traceable to various causes, like fatigue from 36-hour hospital shifts. In one study, Leonidas said, internists slipped in 13 percent of common conditions, like chronic obstructive pulmonary disease.

Dr. Atul Gawande finds fault in doctors than the system in his book, Complications: A Surgeon’s Notes on the Imperfect Science. Says he: “In most cases, it wasn’t technology that failed. Rather, the physician did not consider the right diagnosis in the first place. The perfect test or scan may have been available, but the physician never ordered it. Instead, he ordered another test — and believed it.”

Autopsies are the best detectors of misdiagnoses. Yet less and less autopsies are being done in the US, perhaps to avoid malpractice suits. Same in Philippine government and provincial hospitals.

At any rate, if misdiagnoses are so prevalent today, it must have been worse three to four decades ago. And since there is that chance that his doc erred in 1975, Tito-Sen might wish to suspend belief. For, on the other side of the debate is a report of over 78,900 confirmed abortions in 2000. How confirmed? The mothers checked into government hospitals due to complications from ending the unwanted pregnancies.

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It’s amazing how many readers are interested in rice culture to help farmer-friends and kin. Immediately they researched the Web on “System of Rice Intensification” when I plugged it last Wednesday. SRI-Pilipinas got swamped with farmers’ texts — a happy problem — for free primers and instructions (0939-1178999; 0917-8117747). All wanted to match the Indian growers who in 2009 adopted the SRI and by 2011 were notching world records in rice harvest of more than 380 cavans per hectare. (One Indian notched 448 cavans per hectare. The Philippine average is only 80 cavans.)

The Cornell University website on SRI calls it a set of principles and practices to increase yield of irrigated rice. It involves techniques like:

• Transplanting seedlings younger than usual, 8-12 days old, with only two small leaves, quickly but carefully for minimum trauma to the roots, singly in one hill instead of the usual three to four together to avoid root competition, widely spaced for greater root and canopy growth, in a square grid pattern 25x25 cm or wider; and

• Soil kept moist but well drained and aerobic, with enough organic matter; minimum water during vegetative growth, and thereafter only a thin layer on the field during flowering and grain filling; composting; and regular weeding.

For more info — free — send name and address to Roberto “Ka Obet” Verzola, SRI-Pilipinas, at the hotlines above.

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Catch Sapol radio show, Saturdays, 8-10 a.m., DWIZ (882-AM).

E-mail: [email protected].