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How do we measure patient satisfaction?

vital signs

Pneumonia is asthma. A serious blood regulation condition is anxiety. A concussion is also anxiety. Chronic bronchitis is “just allergies.” Cancer tumor hemorrhage is gas pain.

These are just a few of the misdiagnoses that Duke Student Health providers have made.

I have listened to stories of misdiagnoses from undergraduates and graduate students, current students and alumni, who all resoundingly agree that Student Health needs to seriously reexamine its patient services.  

The Duke Student Health Advisory Committee consists of approximately 12 undergraduate and graduate students, who meet monthly with administrators. The undergraduate committee, which serves as a subcommittee of Duke Student Government, also meets separately twice a month.

The undergraduate Student Health Advisory Committee—commonly known as SHAC—has worked alongside Student Health to implement projects such as adding an over-the-counter vending machine that provides emergency contraception in the Bryan Center, creating a mindfulness room in Perkins and distributing K-Ville Wellness Care Packages during tenting season.

SHAC chair Nico Bodkin said that the university-wide committee has discussed the reported experiences in this column, but Student Health administrators agreed that those were one-off cases and responses in the patient satisfaction survey show overwhelmingly positive feedback.

When I asked John Vaughn, director of Student Health Services, for an anonymized version of student’s patient satisfaction survey responses, he instead responded with a short summary report of the responses between Aug. 1 and Nov. 1, which shows ratings of 92.6% or above in categories such as “experience with nurses,” “doctor being informative regarding treatment,” and “overall experience.”

Bodkin said that the undergraduate committee also discussed the column in their biweekly meeting and shared some of the concerns raised, but they were unsure of what could be done, because the quality of care had always been beyond the scope of SHAC, which “serves in an advisory capacity to [the] administration,” he wrote in an email.

Nonetheless, Bodkin mentioned some “preliminary ideas” for improvement that the committee will discuss with administrators this semester, such as “[implementing] a better follow-up system through MyChart and exploring possible improvements to the current referral system.”

Even though Bodkin’s desire to mitigate the concerns was clearly genuine—in fact, he was the one who reached out, asking for any suggestions I had—his confession that the undergraduate committee’s influence is limited to meeting with administrators monthly and organizing health-related projects outside of the Student Health clinic is disconcerting.

If SHAC is a subcommittee of DSG, then should its primary responsibility not be fighting for the welfare of the students it’s representing? And what issue could be more pressing than the misdiagnosis of sick students?

Through reporting on Student Health in the past six months, I have noticed particular areas of patient services that demand improvement.

The patient satisfaction survey, which Vaughn uses to argue against any doubts of Student Health services, is sent out monthly to a random sample of patients who visited the clinic that week.

But a patient typically does not recognize that they have been misdiagnosed until weeks, if not months, after the fact. And after enduring the troubles of being misdiagnosed and perhaps gaslighted, the student is unlikely to dig through their email for that survey link to share their experience with a clinic that refused to listen in the first place.

Almost every student who shared their experience with me discussed feeling a dismissive or careless attitude from the provider. It manifests in behaviors such as acting frustrated when a patient asks for further testing, casting aside health concerns or refusing to listen when a student pushes back on a diagnosis.

At the end of the clinical notes uploaded onto MyChart after a Student Health visit is the following statement, “This plan was discussed with the patient and questions were answered. There were no further concerns. Follow up as indicated, or sooner should any new problems arise, if conditions worsen, or if they are otherwise concerned.”

However, in every case reported in this column, the provider failed to communicate to the patient that if their symptoms continue or worsen, they should return for a follow-up. And oftentimes the student still had doubts or concerns after leaving the clinic. The automated statement on MyChart indicates expectations failed to be met.

A fundamental breakdown in provider-patient communication exists in Student Health, requiring additional training and real-time evaluations of how doctors and nurses interact with students.

Misdiagnosing students in a university health center is not exclusively a Duke problem. Vassar College’s Boilerplate magazine released an online survey asking for students’ experiences with the school’s medical services. Of the 66 responses, 27 explicitly discuss misdiagnoses, while most of them mention general negligence and insensitivity towards patient concerns.

At the University of Maryland, an adenovirus outbreak exacerbated by mold infestation in the dorms killed first-year Olivia Paregol. Her roommate Megan also experienced symptoms and visited the student health center, where a physician assistant administering a breathing test asked whether “she was trying hard enough” because her oxygen levels had dropped, according to the Washington Post.  

In an email to administrators about how she had been treated, Megan wrote, “[I]t made me feel my symptoms were pushed under the rug yet again…The lack of communication and lack of acknowledgement of the issue saddens me and comes across as if the University puts student health as a low priority.”

I emailed the American College Health Association, asking whether it has done research on misdiagnoses at student health clinics or has recommendations for avoiding these potentially fatal mistakes. The director of communications responded saying that the association has neither data nor recommendations regarding this topic.  

As I discussed in the previous column, diagnostic error is a national issue that receives insufficient attention and lacks data or reliable measures.

While we are not the only ones to blame, the University needs to take immediate responsibility for the welfare of its students. This is an opportunity for Duke—a leader in research and higher education—to step up as also a leader in student health. 

Rose Wong is a Trinity senior and a Local/National News Editor. 

Editor’s note: This column is part of a recurring series on health at Duke called “vital signs.” If you have experienced a misdiagnosis at Student Health, contact Rose Wong at rosanna.wong@duke.edu.

The undergraduate Student Health Advisory Committee is actively seeking feedback on Student Health to better inform their monthly conversations with administrators. Contact them here with your concerns and/or suggestions for improvement.

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