Diagnostic overshadowing at Flagstaff Medical Center — and what it costs
Ing Says: Diagnostic Overshadowing Must Be Discussed and Made Explicit
There is a phenomenon in medical research called diagnostic overshadowing.
It has been documented by the Agency for Healthcare Research and Quality, studied in emergency medicine, and identified as a significant driver of disparate health outcomes for people with psychiatric histories. It occurs when a patient’s mental health diagnosis — or the mere fact of a psychiatric history — causes clinicians to attribute new, unrelated physical symptoms to that history rather than investigating them on their own terms.
In plain language: the chart walks in before you do. And once the chart has spoken, the clinician has already decided what they are seeing.
I experienced diagnostic overshadowing at Flagstaff Medical Center. This is what actually happened.
What Happened
I came to the emergency room with a corneal injury. I was in significant pain — the kind of acute, escalating pain that corneal injuries produce, because the cornea is one of the most densely innervated surfaces of the human body. I also presented with severe tachycardia.
The ED diagnosed the injury and prescribed treatment. Four days later — after following that prescribed treatment — I was still in enough pain and distress that I saw an ophthalmologist. The ophthalmologist diagnosed a corneal scratch.
Let that sink in: four days of prescribed ED treatment, and the injury required specialist follow-up to be accurately identified. That is the clinical picture. That is what I was dealing with.
What I believe happened in that ED, and what is made highly likely in my chart — and I want to be precise about what I can and cannot prove — is that the triage nurse saw my psychiatric history in my chart before she saw me. And that what she decided, looking at that chart and then at me, was that my increasing pain was psychiatric in origin. Whether she used the word “manipulative” I cannot say. But that possibility was present in the room. Survivors of mental health system harm learn to feel it.
What I can say with confidence: I was kept waiting for treatment for a vision-threatening injury with severe tachycardia for longer than I believe is clinically defensible. I did eventually receive care. The delay is what I am documenting.
One more thing worth noting: when the treating physician documented my injury, he recorded it as a corneal abrasion rather than the corneal scratch the ophthalmologist would diagnose four days later. I think he knew I had waited too long for something this serious. I cannot prove that. It is less important than the delay itself — but it stayed with me.
What Diagnostic Overshadowing Actually Is
Let me be direct about something the research literature is often too careful to say plainly.
Diagnostic overshadowing is bigotry.
It is discrimination against people with mental illness, operating inside a clinical setting, wearing the clothing of professional judgment. The fact that the clinician may not experience it as bigotry — may not recognize it as such, may genuinely believe they are making a neutral triage decision — does not change what it is. Bigotry does not require self-awareness to cause harm. It requires only that one group of people be treated as less credible, less urgent, less deserving of care than another — based not on their clinical presentation, but on who they are.
We do not excuse other forms of healthcare discrimination by saying the provider didn’t understand they were being racist, or sexist, or ableist. We name the discrimination and hold the institution accountable for it.
The same standard applies here.
I do not care why they are bigoted. I care that they are — and that institutions like Flagstaff Medical Center refuse accountability for the culture, the training, and the protocols that allow it to continue.
Flagstaff Medical Center Is Not Alone — But It Is Accountable
Flagstaff Medical Center did not invent diagnostic overshadowing. It is a systemic problem in emergency medicine, in psychiatric consultation, in primary care. It is documented in the research literature. It is named in quality improvement frameworks. It is known.
That is exactly the problem.
Flagstaff Medical Center knew, or should have known, that patients with psychiatric histories are vulnerable to this exact failure in emergency triage settings. The research is not obscure. The disparity is not subtle.
What training exists to interrupt diagnostic bigotry before it reaches the triage desk?
The Diagnostic Bias Pipeline
Diagnostic overshadowing does not operate in isolation. It is one piece of a larger system of discrimination that shapes the experience of people with psychiatric histories throughout healthcare.
And it connects to the documented reality that this discrimination is not equally distributed. People with serious mental illness die, on average, decades earlier than the general population. Undertreated physical illness is a significant part of that picture. So is the triage desk that read a chart and decided increasing pain was psychiatric. So is the delay that followed.
I received care at Flagstaff Medical Center. I am not saying otherwise. What I am saying is that the delay was dangerous — and that the most plausible explanation for that delay is the chart that walked in before I did.
If This Mirrors Your Experience
You are not alone. What happened to you was not inevitable. It was a judgment call made at a triage desk, shaped by a system that still treats psychiatric history as a reason to look away rather than look closer.
Judgment calls can be documented, reported, and challenged.
File with your state’s medical board. File with the Office of Civil Rights. File with the Joint Commission, which accredits Flagstaff Medical Center and has a formal complaint process for concerns about patient safety and equitable care.
File knowing that these bodies rarely impose meaningful consequences — because the record matters regardless.
And then come to us. Between Trust and Trauma documents what happened, names the providers and facilities responsible, and connects survivors who experienced the same pattern of harm.
One incident is enough. One person harmed is enough. We document it because it happened — not because we need a pattern to justify our pain.
“Nothing About Us Without Us.”
