Evelyn Vargas was told, in three separate settings over fourteen months, that what she was feeling was anxiety. She did have anxiety. That was the clever part of it.
The change was administrative rather than clinical. Certain patients were flagged to a named clinician, and the booking system stopped offering them anyone else.
The referral letter was rewritten to lead with the question rather than the history, which cut a round of clarification out of most onward pathways.
One appointment being wrong is medicine. Three appointments reaching the same wrong conclusion is a system problem.
Illustrative composite
The practice runs a flag on anyone presenting three times with the same complaint and no diagnosis, regardless of what was concluded each time.
“Now something’s job is to look at the whole shape of it,” she says. “That’s the change.”
