Diagnostic Overshadowing




I was trying to get through a pile of non-Addiction Medicine journals when I came across an article titled “The Ethics of Behavioral Health Information Technology: Frequent Flyer Icons and Implicit Bias,” in the October 18th, 2016, issue of the Journal of the American Medical Association.


According to the authors, Michelle Joy M.D. et al, at least one electronic medical record (EMR) system provides a way to display an icon shaped like an airplane, as a way to inform treating physicians that the patient is a “frequent flyer.” This term has long been used to describe patients who repeatedly come to emergency departments or other providers on a regular basis.

This term has been used for decades. I’ve used it myself in the past. It’s a short-hand phrase that usually means, “This patient is a pain in the ass because he/she keeps coming back for inappropriate reasons.” More elegantly and succinctly, the authors of this article say the term frequent flier is short-hand for “problem patient.”

This article points out the ethical harms of stigmatizing patients in this manner, and presents the term “diagnostic overshadowing.” This means a physician’s attitude towards a patient can be skewed by the idea that the patient is seeking care for inappropriate reasons. The article goes on to cite studies showing patients with mental health conditions are less likely to get appropriate medical care compared to patients without mental health issues, likely due to this diagnostic overshadowing.

I see this every week in my patients with opioid use disorder. Even my patients who are in recovery and doing well say they are treated differently when they go to our local hospital emergency departments, or even to their primary care doctors. After they reveal they’re on buprenorphine or methadone to treat opioid use disorder, they detect changes in the attitudes of their care providers.

Often, the patient will say, “I know I’ve tried to score drugs from him before, but this time I didn’t get a chance to say anything before the doctor accused me of being a drug seeker.” The doctor, reading the past records, jumped to the conclusions that this person is only in the emergency department to get pain pills. The doctor shuts down further communication because of his diagnostic overshadowing. The patient doesn’t get a chance to receive appropriate care. Maybe just as bad, that patient is given the message that they don’t deserve respect, due to their diagnosis of opioid use disorder.

If this happens to patients years after they’ve been in recovery, just think about what happens to people in active opioid use disorder. They are pre-judged as drug seekers, and the emergency department doctors sometimes decide, before gathering information, that the addicted person has no valid medical problems. The doctor starts with an assumption that the patient is a bad person, rather than a sick person.

This attitude leads to medical disasters. Patients with current intravenous drug use are more likely, not less likely, to have serious medical problems.

I’ve seen two patients who had serious infectious medical emergencies that were missed by local emergency room doctors. Both patients were seen multiple times at two local hospital emergency departments. Both said they were treated with distain by personnel. One was seen a total of four times before she went, on her own, to the emergency department of a nearby teaching hospital, where she was immediately diagnosed, and taken for emergency surgery.

I believe these two patients encountered doctors who experienced the diagnostic overshadowing described in the JAMA article, because they had opioid use disorders. Their doctors assumed they only wanted pain pill prescriptions and weren’t all that sick.

What do we do about diagnostic overshadowing?

We must educate physicians more completely about addiction and mental health disorders. I’ve written in previous blog posts about the lack of training, at least in the past, for physicians about substance use disorders. Specific training in medication-assisted treatment of opioid use disorders wasn’t taught at all. This is slowly changing, and medical schools now teach students about these vital medical problems. This will help younger physicians, who are getting their training now.

What about older doctors, already in practice? I think all of us working in substance use disorder and mental health disorder fields have an obligation to educate our peers. I know I held significant bias against methadone before I knew anything about it. One doctor friend encouraged me to read and learn. When I did, I found piles of information supporting this evidence-based treatment.

Now I try to pass along what I’ve learned. Sometimes I’m successful, sometimes not. I’ve talked to doctors in my community, with a wide range of results. Some physicians have become allies, supportive of the patients we share. Others have not been willing to listen or learn about MAT. One doctor told me if I prescribe MAT for one of his patients, he will dismiss that patient from their practice.

The only difference between this doctor and me was in our willingness to learn. Had I not agreed to read some of the tons of studies showing that methadone helps patients with opioid use disorder, I’d still be opposed to methadone, as he continues to be. It’s a reminder to remain teachable.

It’s easy to become frustrated with my colleagues. For example, I can’t remember even one patient being referred to our opioid treatment program by the local hospital’s emergency department physicians. I have not been successful at educating these doctors.

Up until this last month, we didn’t get referrals from our local substance abuse and mental health treatment provider for the county. One patient specifically asked them to refer her to a methadone clinic, and was told, “We don’t do that.” Fortunately, she had friends who told her where to find our treatment center.

Our program manager, nurse manager, and I met with the treatment program’s supervisors, who said they had no idea their facility was trying to prevent patients from accessing opioid treatment programs. They promised to fix the situation.

Thankfully, something changed, and we just got our first few referrals from this program over the last two weeks. I see this as a tremendous success of advocacy, though it took our program manager quite some time to get through to their management.

In a blog earlier this year, I described how the local detox center wants to provide Intensive Outpatient Program for our patients on methadone and buprenorphine. That’s a collaboration I didn’t think would ever happen, yet in a few weeks I hear their program will be ready for our patients.

So things do change, but not quickly. All of us advocating for MAT need to be patient, yet persistent. Maybe then we can eliminate diagnostic overshadowing for our patient populations.



6 responses to this post.

  1. Posted by Cheryl Kupras on November 13, 2016 at 11:02 pm

    I could fill a book with stories of people with Substance Use Disorders being dismissed as drug seeking- the 3 that come to mind were 1) a gentleman,who was addicted to heroin that cam to the ER of my public hospital with a raging infection in both arms-they put him on oral antibiotics and sent him away-they next week both of his arms were amputated, he went to a nursing home where he died of throat cancer a few years later 2) a woman who relapsed to heroin use after 12 years of sobriety after not being able to get treatment for her kidney stones due to her history of addiction. Once she got on Methadone, she was seen by a compassionate MD (Delaney Ruston) who finally gave her Litho to remove the stones and 3) a woman with schizophrenia, on medication and stable on Methadone for years with foot pain that was so debilitating she was wheelchair bound before finally being diagnosed with something that I can’t recall the name at this moment.


  2. Posted by belle on November 14, 2016 at 2:37 am

    I believe there should be a new sub-practice Addiction Medicine Physical. I am sure there is a much more elegant way to put it. What I mean by this is Doctors or NP’s who
    Soley treat the physical ravages of addiction. This kind of practice would treat those of us older recovering addicts who may have Hep C. It might have saved my beloved friend who worked in alternative medicine, but succumbed to an Aortic Aneurysm at 49.
    Latent Syphilis? Perhaps. I never reveal my year in a theraputic community in 1973. I recently checked – those pre-computer records are gone. Much relief.

    But if there was such a specialty, perhaps I could request that Syphilis test and then I
    Could be completely honest about my myriad medical problems. Neurological primarily.

    My older son. Who has been clean a decade had a terrible experience this Summer that triggered profound PTSD. His Primary care clinic refused him medication because he is an MMA user. He literally had to break out of the clinic when they brought in the substance abuse counselor. My husband texted him to keep him from jumping off a bridge. An Addiction Doctor Ally would ( I hope) have made a different call. Son 1 has changed clinics, but still gets calls from the SA counselor.

    Son 2 is back on Vivitrol.and in a better for him program now where his mental health needs are addressed. But I worry about the physical repercussions of having been revived by Narcan in July. And he hesitates to get other medical matters addressed.
    He has. Genetic Iron Overload disease (Hereditary Hemochromatosis). He should be getting ferritin levels taken regularly, and needs to have liver function tests.

    With the current Opiate crisis, there must be thousands in need of compassionate non-judgmental Medical care in private practices, clinics and ER’s. Were I to win Lotto and become a Mega-Millionaire, I would fund such a specialty somewhere.

    What a sad irony; beating addiction but dying from a treatable condition because of your history.


  3. I have unfortunately had to take ER doctors outside of my fiance’s room and say to them “I hope you are treating my fiancé the same way you would any other patient not being treated for opioid use disorder with methadone because I would hate to find out through your past records in a legal action that you are giving her a different standard of care and even possibly violating the Americans with disabilities act” unfortunately that’s how bad it gets for those who can’t advocate for themselves. Fortunately they tend to treat her much better after that talk.


  4. Posted by kim coffey on October 16, 2020 at 2:21 pm

    I am just now seeing all of this my daughter has been an iv user off and on but in feb 2020 is when it hit a wall she went to a hospital they did an xray seen she had a shadow on her left rib and instead of doing a CT to find out what it was they said follow up with your family doctor. Told her it was a pulled muscle in her chest. she told them up front she was an iv user of opanas and she was short of breath,and chest pain and she thought it might be endocarditis. Didn’t listen sent her out the door with napoxen. Two weeks later she ends up in the ER different hospital is admitted with pulmonary emboli septsis. 3 days later open heart surgery to take out her triscupid valve and 3 weeks after amputiton of all her toes on left foot.


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