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 last year, 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, and we now get referrals from this program.

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.



10 responses to this post.

  1. Posted by Icecutter on March 18, 2018 at 4:42 pm

    I have been in MAT for 17 years now. I have found when in a situation with a new physician, who does not know my history, that being upfront about my addiction and treatment helps a great deal. For example, in providing my medication information, I will say, “methadone, XX mgs daily” and then add either, “I am an addict” or, sometimes I will say, “I am opiate dependent”. With this approach, you show that you are not hiding your addiction, rather, it tells the provider that you have recognized your addiction and taken steps to control it. Giving this information in a calm, matter of fact voice, takes all the drama and mystique out of it, as it should be. It also helps the provider treat you, because if you do indeed need pain medication, the provider will know that you will require higher doses than a non-addict would. You should also provide your MAT’s clinic’s or the prescribing physician’s phone number for verification.
    If you feel that the doctor’s response to this information is overshadowing his/her opinion or treatment of you, you may respectfully request another doctor or simply say, “Yes, unfortunately, until I began treatment for my addiction, I was guilty of that type if drug seeking behavior, but since I began treatment with XXXXXXXXXX it has relieved me of that behavior pattern”.


    • Posted by Brooke Stanley on March 19, 2018 at 4:01 pm

      Well said! I feel like I can take control of the situation by being the one to inform the doctor, verses him/her discovering it on their own. I feel that being on MMT comes with certain responsibilities, which include being upfront about being in treatment. And to your point, it removes the likelihood for any drama. In my early years of treatment, I was terrified any time that I went to the doctor or dentist because I feared that they would find out my “secret.” Not having a “secret” is liberating and makes me much less fearful. I am probably still guarded to an extent, as I anticipate possible judgement, but I definitely feel like times are changing. I recently had an appointment with a cardiologist and was very nervous. I was upfront, when I called and made the appointment, that I was on methadone and I also noted how long I had been in recovery (so that the correlation could be made that MMT was working for me). I was delighted when, after my EKG and exam, the cardiologist took me to his office to discuss my success on methadone. He not only praised me, but asked what more he could do to convince other patients, addicted to opiates, to give MAT a try. He quizzed me about my success and never once did he ask the question that everyone else wants to ask, “When are you getting off.” Before I left, I commented to him that I appreciated him not asking me about detoxing. He responded, “Why would I suggest that you get off a medicine that is clearly working so well.” His response was refreshing! Had I not been honest with him, I would have missed this opportunity.


  2. Posted by Neil Goldberg, MD on March 18, 2018 at 5:18 pm

    The frequent flier “airplane” is probably not appropriate. But, failure to identify substance use as part of the vital, prominently recorded patient history isn’t either. As a radiologist, I see innumerable studies which are related in some way to substance use, from CT for brain death to hand x-rays for osteomyelitis. I have been distressed seeing CT studies done monthly on patients who present for, “non specific diffuse abdominal pain,” only to find out after speaking with the ER physician that the patient has a history of substance use. Stigmatizing patients is one thing. Radiating them incessantly every time someone with a substance use/abuse reports symptoms is another. It’s not such a simple problem. Substance use/abuse should be prominently featured in patient history (which is difficult to get from physicians to begin with) no less than DM, or HTN. I can tell you that it tends not to be and perhaps this results from physicians who fear accusation of stigmatizing patients with documentation in the chart. It wouldn’t be the first time.


    • Dr. Goldberg, thank you so much for putting your unique knowledge and perspective here for us to see. I find it quite interesting and valuable to know.

      I have been on MAT since 1996 and actively practiced addiction from 1986 til then. Suboxone I’ve been taking, gratefully, since it came to the US.

      Although I feel pretty darn stable and it’s unlikely I’ll relapse, what you’ve written here makes it even more unlikely. It’s a great deterrent for me personally, as I was the one who showed up in the doctor’s offices and emergency departments with both physical and emotional issues needing treatment that seemed to interplay or something. It’s all been decades ago and I have distance and more clarity—but I don’t want that to be me. Or anyone else. So thank you! I hope more people see your post.


  3. Posted by Scott on March 19, 2018 at 6:56 am

    Sorry for the length of this comment I always go a bit overboard to ensure what I write has context….

    As someone on Suboxone who also suffers regular episodes of as yet unexplained abdominal pain, this is a topic of interest to me. I haven’t had the pain looked into since prior to my period of opioid misuse, so I’ve not had to face this situation yet.

    My pain is “diagnosed” as IBS and I’ve been checked over enough to know it’s nothing serious. That’s why I don’t have a sense of urgency about getting it checked again. I do need to though as the pain is severe and I’ve been unsatisfied with the prognosis (nothing we can do) and the treatment (buscopan/immodium).

    If asked to rate the pain out of 10 I’d call it a 9/10 at its peak – fluctuating from 5 to 9 for 1-6 weeks at a time. When it hits a 9 I’m in bed with a hot water bottle and paracetamol for days. Suboxone doesn’t even touch this pain. The only worse pain I’ve ever had was when I hurt my back. I couldn’t even walk then.

    I have been to the doctor many, many times over the years about it. Maybe I’m a frequent flyer? I have never been prescribed pain meds for it though.

    I’m in Australia so things are probably a little different where patterns of opiate prescribing are compared, but I imagine general attitudes amongst doctors to be similar.

    My current GP (I relocated 18 months ago) is also my Suboxone prescriber, so I don’t tend to see other doctors often. It’ll come up sooner or later though as I need this issue resolved.

    Reading this makes me much more hesitant about seeing anyone for it now. I have never, ever doctor shopped or lied to get meds, and if following up on my abdominal pain caused the words “drug seeking behaviour” to end up on my record next to the words “Suboxone patient” I’d be furious.

    Also, as a side note, how is it acceptable for doctors to be opposed to methadone? Would we accept a doctor who is opposed to chemotherapy? Or a doctor who refused to treat type 2 diabetes with medication and said it was just replacing a healthy diet and exercise with drugs? If a doctor is opposed to methadone he/she should (be forced to) find a new career path where he/she doesn’t have any responsibility for managing human health.


  4. Great read. I would like to say that, first as a substance abuse counselor and even one that is in recovery from opiate addiction, I(we) was guilty of the same practice. One example would be if I suspected someone on my caseload of, let’s say-chronically diverting their urine sample- I would put an asterisk next to their name. Logically carry that one step further and assume I have to transfer patients to new counselors frequently, and you have a bias. As for the Doctors, I have to tread lightly myself even with 12 years of recovery. Respecting my recovery, I have woven the words recovery and opiates into my rhetoric when dealing with any DDS or GP and have received a less than warm welcome in almost every situation here in Mooresville. As I build my recovery services I certainly will be looking for opportunities to help educate Iredell as I did earlier in my recovery. An enlightened community is a safer community.


    • So true! Physicians and probably dentists too are not well-educated about substance use disorders. However, there is some momentum building for changing this gap in medical education, both for medical schools and residency programs.
      I agree – more knowledge is better for the community!


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