This post was written by Maggie Mahar and Niko Karvounis
Despite all of the talk about medical errors and patient safety, almost no one likes to talk about diagnostic errors. Yet doctors misdiagnose patients more often than we would like to think. Sometimes they diagnose patients with illnesses they don’t have. Other times, the true condition is missed. All in all, diagnostic errors account for 17 percent of adverse events in hospitals according to the “Harvard Medical Practice Study,” a landmark study that looks at medical errors.
Traditionally, these errors have not received much attention from researchers or the public. This is understandable. Thinking about missed diagnosis and wrong diagnosis makes everyone—patients as well as doctors—queasy. Especially because there is no obvious solution. But this past weekend the American Medical Informatics Association (AMIA) made a brave effort to spotlight the problem, holding its first-ever “Diagnostic Error in Medicine” conference.
Hats off to Bob Wachter, Associate Chairman of the Department of Medicine at the University of California, San Francisco, and the keynote speaker at the conference. On Monday, Wachter shared some thoughts on diagnostic errors through his blog, “Wachter’s World.”
Wachter begins by pointing out that a misdiagnosis lacks the concentrated shock value that is needed to grab the public imagination. Diagnostic mistakes “often have complex causal pathways, take time to play out, and may not kill for hours [i.e., if a doctor misses myocardial infarction in a patient], days (missed meningitis) or even years (missed cancers).” In short, to understand diagnostic errors you need to pay attention for a longer period of time—not something that’s easy to do in today’s sound-bite driven culture.
Diagnostic errors just aren’t media friendly. When someone is prescribed the wrong medication and they die, the sequence of events is usually rapid enough that the story can be told soon after the tragedy occurs. But the consequences of a mistaken diagnosis are too diffuse to make a nice, punchy story. As Wachter puts it: “They don’t pack the same visceral wallop as wrong-site surgery.”
Finally, Wachter observes, it’s hard to measure diagnostic errors.
It’s easy get an audience’s attention by telling them that “the average
hospitalized patient experiences one medication error a day” or that
“the average ICU patient has 1.7 errors per day in their care.”
But we don’t have equally clean numbers on missed diagnoses. As a
result, he points out, “it’s difficult to convince policy makers and
hospital executives, who are now obsessing about lowering the rates of
hospital-acquired infections and falls” to focus on a problem that is
much more difficult to tabulate.
This is a recurring problem in programs that strive to improve the
quality of care: we are mesmerized by the idea of “measuring”
everything. Yet, too often, what is most important cannot be easily
measured.
Wacther recognizes the urgency of the problem: “As quality and safety
movements gallop along, the need to” address Diagnostic Errors “grows
more pressing,” he writes. “Until we do, we will face a fundamental
problem: a hospital can be seen as a high quality organization –
receiving awards for being a stellar performer and oodles of cash from
P4P programs – if all of its ‘pneumonia’ patients receive the correct
antibiotics, all its ‘CHF’ patients are prescribed ACE inhibitors, and
all its ‘MI’ patients get aspirin and beta blockers.
“Even if every one of the diagnoses was wrong.”
Why So Many Errors?
Medicine is shot through with uncertainty; diseases do not always
present neatly, in textbook fashion, and every human body is unique.
These are just a few reasons why diagnosis is, perhaps, the most
difficult part of medicine.
But misdiagnosis almost always can be traced to cognitive errors in how
doctors think. When diagnosis is based on simple observation in
specialties like radiology and pathology, which rely heavily on visual
interpretation, error rates probably range from 2 percent to 5 percent,
according to Drs. Eta S. Berner and Mark L. Graber, writing in the May issue of the American Journal of Medicine.
By contrast, in clinical specialties that rely on “data gathering and
synthesis” rather than observation, error rates tend run as high as 15
percent. After reviewing “an extensive and ever-growing literature” on
misdiagnosis, Berner and Graber conclude that “diagnostic errors exist
at nontrivial and sometimes alarming rates. These studies span every
specialty and virtually every dimension of both inpatient and
outpatient care.”
As the table below reveals, numerous studies show that the rate of
misdiagnosis is “disappointingly high” both “for relatively benign
conditions” and “for disorders where rapid and accurate diagnosis is
essential, such as myocardial infarction, pulmonary embolism, and
dissecting or ruptured aortic aneurysms.”
STUDY NAME: Shojania et al (2002)
ASSESSED CONDITION: Tuberculosis of the lungs (bacterial infection)
FINDINGS: Reviewing autopsy studies specifically focused on the
diagnosis of lung TB, researchers found that 50% of these diagnoses
were not suspected by physicians before the patient died.
STUDY: Pidenda et al (2001)
CONDITION: Pulmonary embolism ( a blood clot blocks arteries in the lungs)
FINDINGS: This study reviewed diagnosis of fatal dislodged blood clots
over a 5-yr period at a single institution. Of 67 patients who died of
pulmonary embolism, clinicians didn’t suspect the diagnosis in 37 (55%)
of them.
STUDY: Lederle et al (1994), von Kodolitsch et al (2000)
CONDITION: Ruptured aortic aneurysm (when a weakened, bulging area in the aorta ruptures)
FINDINGS: These two studies reviewed cases at a single medical center
over a 7-yr period. Of 23 cases involving these aneurysms in the
abdomen, diagnosis of rupture was initially missed in 14 (61%); in
patients presenting with chest pain, doctors missed the need to dissect
the bulging part of the aorta in 35% of cases.
STUDY: Edlow (2005)
CONDITION: Subarachnoid hemorrhage (bleeding in a particular region of the brain)
FINDINGS: This study, an updated review of published studies on this
particular type of brain bleeding, shows about 30% are misdiagnosed on
initial evaluation.
STUDY: Burton et al (1998)
CONDITION: Cancer detection
FINDINGS: Autopsy study at a single hospital: of the 250 malignant
tumors found at autopsy, 111 were either misdiagnosed or undiagnosed,
and in just 57 of the cases the cause of death was judged to be related
to the cancer.
STUDY: Beam et al (1996)
CONDITION: Breast cancer
FINDINGS: Looked at 50 accredited centers agreed to review mammograms
of 79 women, 45 of whom had breast cancer. The centers missed cancer in
21% of the patients.
STUDY: McGinnis et al (2002)
CONDITION: Melanoma (skin cancer)
FINDINGS: This study, the second review of 5,136 biopsy samples found
that diagnosis changed in 11% (1.1% from benign to malignant, 1.2% from
malignant to benign, and 8% had a change in doctors’ ranking of how
abnormal the cells were) of the samples over time, suggesting a not
insignificant initial error rate.
STUDY: Perlis (2005)
CONDITION: Bipolar disorder
FINDINGS: The initial diagnosis was wrong in 69% of patients with
bipolar disorder and delays in establishing the correct diagnosis were
common.
STUDY: Graff et al (2000)
CONDITION: Appendicitis (inflamed appendix)
FINDINGS: Retrospective study at 12 hospitals of patients with
abdominal pain and operations for appendicitis. Of 1,026 patients who
had surgery, there was no appendicitis in 110 (10.5%); of 916 patients
with a final diagnosis of appendicitis, the diagnosis was missed or
wrong in 170 (18.6%).
STUDY: Raab et al (2005)
CONDITION: Cancer pathology (microscopic examination of tissues and cells to detect cancer)
FINDINGS: The frequency of errors in diagnosing cancer was measured at
4 hospitals over a 1-yr period. The error rate of pathologic diagnosis
was 2%–9% for gynecology cases and 5%–12% for non-gynecology cases;
errors ran from what tissues the doctors used, to preparation problems,
to misinterpretations of tissue anatomy when viewed under microscope.
STUDY: Buchweitz et al (2005)
CONDITION: Endometriosis (tissue similar to the lining of the uterus is found elsewhere in the body)
FINDINGS: Digital videotapes of the inside of patients’ bodies were
shown to 108 gynecologic surgeons. Surgeons agreed only 18 percent of
the time as to how many tissue areas were actually affected by this
condition.
STUDY: Gorter et al (2002)
CONDITION: Psoriatic arthritis (red, scaly skin coupled with join inflammation)
FINDINGS: 1 of 2 patients with psoriatic arthritis visited 23 joint and
motor specialists; the diagnosis was missed or wrong in 9 visits (39%).
STUDY: Bogun et al (2004)
CONDITION: Atrial fibrillation (abnormal heart beat in the upper chambers of the heart)
FINDINGS: Review of doctor readings of electro-cardiograms [a graphical
recording of the change in body electricity due to cardiac activity]
that concluded a patient suffered from this abnormal heart beat found
that: 35% of the patients were misdiagnosed by the machine, and the
error was detected by the reviewing clinician only 76% of the time.
STUDY: Arnon et al (2006)
CONDITION: Infant botulism (toxic bacterial infection in newborns’ intestines)
FINDINGS: Study of 129 infants in California suspected of having
botulism during a 5-yr period; only 50% of the cases were suspected at
the time of admission.
STUDY: Edelman (2002)
CONDITION: Diabetes (high blood sugar due to insufficient insulin)
FINDINGS: Retrospective review of 1,426 patients with laboratory
evidence of diabetes showed that there was no mention of diabetes in
the medical record of 18% of patients.
STUDY: Russell et al (1988)
CONDITION: Chest x-rays in the Emergency Department
FINDINGS: One third of x-rays were incorrectly interpreted by the
Emergency Department staff compared with the final readings by
radiologists.
Citation: Schiff GD, Kim S, Abrams R, et al.. Diagnosing diagnosis errors: lessons from a multi-institutional collaborative project. Advances in Patient Safety: From Research to Implementation. Rockville: MD: Agency for Healthcare Research and Quality; 2007;vol 2. February 2005. AHRQ Publication No. 050021. Available at: http://www.ahrq.gov/downloads/pub/advances/vol2/schiff.pdf./
Overconfidence
Misdiagnosis rarely springs from a “lack of knowledge per se, such as
seeing a patient with a disease that the physician has never
encountered before,” Berner and Grave explain. “More commonly,
cognitive errors reflect problems gathering data, such as failing to
elicit complete and accurate information from the patient; failure to
recognize the significance of data, such as misinterpreting test
results; or most commonly, failure to synthesize or ‘put it all
together.’”
The breakdown in clinical reasoning often occurs because the physician
isn’t willing or able to “reflect on [his] own thinking processes and
critically examine [his] assumptions, beliefs, and conclusions.” In a
word, the physician is too “confident.”
Indeed, Berner and Graber find an inverse relationship between
confidence and skill. In one study they reviewed, the researchers
looked at diagnoses made by medical students, residents and physicians
and asked them how certain they were that they were correct. The good
news is that while medical students were less accurate, they also were
less confident; meanwhile the attending physicians were the most
accurate, and highly confident. The bad news is that the residents were
more confident than the others, but significantly less accurate than
the attending physicians. In another study, researchers found that
residents often stayed wedded to an incorrect diagnosis even when a
diagnostic decision support system suggested the correct diagnosis.
In a third study of 126 patients who died in the ICU and underwent
autopsy, physicians were asked to provide the clinical diagnosis and
also their level of uncertainty. Level 1 represented complete
certainty, level 2 indicated minor uncertainty, and level 3 designated
major uncertainty. Here the punch line is alarming: clinicians who
were “completely certain” of the diagnosis before death were wrong 40%
of the time.
Overconfidence or the belief that “I know all I need to know” may help
explain what the researchers describe as a “pervasive disinterest in
any decision support or feedback, regardless of the specific
situation.” Studies show that “physicians admit to having many
questions that could be important at the point of care, but which they
do not pursue. Even when information resources are automated and easily
accessible at the point of care with a computer, one study found that
only a tiny fraction of the resources were actually used.”
Research shows that physicians tend to ignore computerized
decision-support systems, often in the form of guidelines, alerts, and
reminders. “For many conditions, consensus exists on the best
treatments and the recommended goals,” Berner and Graber point out.
Nevertheless, a comprehensive review of medical practice in the United
States found that the care provided deviated from recommended best
practices half of the time. In one study, the researchers suggest that
the high rate of noncompliance with clinical guidelines relates to “the
sociology of what it means to be a professional” in our health care
system: “Being a professional connotes possessing expert knowledge in
an area and functioning relatively autonomously.” Many physicians have
yet to learn that 21st century medicine is too complex for anyone to
know everything—even in a single specialty. Medicine has become a team
sport.
But while it’s easy to blame medical “arrogance,” for the high rate of
errors, “there is ubstantial evidence that overconfidence— that is,
miscalibration of one’s own sense of accuracy and actual accuracy—is
ubiquitous and simply part of human nature” Berner and Graber write. “A
striking example derives from surveys of academic professionals, 94% of
whom rate themselves in the top half of their profession. Similarly,
only 1% of drivers rate their skills below that of the average driver.”
In another study published in the same issue of AMJ, Pat Croskerry and Geoff Norman note
that such equanimity regarding one’s own skills can lead to what’s
called “confirmation bias.” People “anchor” on findings that support
their initial assumptions. Given a set of information, it’s much easier
to pull out the data that proves you right and pat yourself on the back
than it is to look at the contradictory evidence and rethink your
assumptions. Indeed, Croskerry and Norman observe:,“it takes far more
mental effort to contemplate disconfirmation–by considering all the
other things it might be– than confirmation.”
Making things all the more difficult is the fact that, at a certain
point, the alternative to confirmation bias—what Croskerry and Norman
call “consider the opposite”—becomes impractical. If a doctor embraces
uncertainty he could easily become paralyzed.
What doctors need to do is to simultaneously make a decision—and keep
an open mind. Often, a doctor must embark on a course of treatment as a
way of diagnosing the condition—all the time knowing that he may be
wrong.
Too often, Berner and Graber observe, physicians narrow the diagnostic
hypotheses too early in the process, so that the correct diagnosis is
never seriously considered. Reliance on advanced diagnostic tests can
encourage what they call “premature closure.” After all, high-tech
diagnostic technologies offer up hard-and-fast- data, fostering the
illusion that the physician has vanquished medicine’s ambiguity.
But in truth advanced diagnostic tools can miss critical information.
The problem is not the technology, but how we use it. Some observers
suggest that the newest and most sophisticated tools are more likely to
produce false negatives because doctors accept the results so readily.
“In most cases, it wasn’t the technology that failed,” explains Dr. Atul Gawande in Complications: A Surgeon’s Notes on an Imperfect Science.
“Rather, the physician did not consider the right diagnosis in the
first place. The perfect test or scan may have been available, but the
physician never ordered it.” Instead, he ordered another test—and
believed it.
“We get this all the time,” Bill Pellan of Florida’s Penallas-Pasca County Medical Examiner’s Office told the New York Times
a few years ago. “The doctor will get our report and call and say: ‘But
there can’t be a lacerated aorta. We did a whole set of scans.’
“We have to remind him we held the heart in our hands.”
In the second part of the post, we’ll address the fact that most
physicians have no way of knowing how often they may be missing the
diagnosis because they don’t receive any feed-back: they never find out
how the story ends. Maggie will also talk about “the most powerful tool
in the history of medicine”—the autopsy.
It sounds like you want to fire all the physicians!
DoctorSH–
Of course not–the physicians are my readers!
Seriously–you’ll notice that virtually everyone I’m quoting is a physician.
This is not about some outside group criticizing physicians, this is about physicians themselves reflecting on misdiagnosis and what to do about it.
In part 2, I’ll explain that even if a doctor isn’t overly confident, he has very little feedback to let him know when gets a diagnosis wrong. And, without feedback, it’s extremely hard to learn from mistakes.
Misdiagnosis is inevitable. And as I note, doctors are hardly the only people who tend to be overly confident about their skills.
Since I drive in Manhattan, (surrounded by Jersey drivers!), I love the fact that 99% percent of all drivers think they’re in the top half.
Right on Maggie. Medicine is so complex, and patients don’t always come forth with information that helps in diagnostics. However, I think mid-diagnoses should be a topic more heavily discussed. Often, docs are watching out for theirs and others backs. Understandable with the threat of malpractice. That is a whole nother part of it that contributes so heavily to the silence.
I’m not a physician and not even in the health care field. I’m a retired engineer. I have always accepted that my doctors are human and subject to making mistakes as all of us do. My father died when he did (age age 94) because his hospital missed that he had a subdural hematoma from a fall that brought him to the hospital. They found nothing wrong with him. When he had continued problems from the hematoma they even refused to consider that his previous fall might be the cause. It took an argument by my brother and I to convince his physician to look into that possibility, but it was too late then to correct his problem.
I was not embittered by that experience. Both my wife and I have had our own experiences with mistakes by our physicians. We both just accept that God isn’t available as a physician of choice, so we accept that mistakes can happen.
During my work career I also made some mistakes. Surprise!
Great topic Maggie but extremely complex. In 1998 I designed a study to look at how accurately CT scans could identify deep neck infections. First problem: what was the gold standard to be? Long term follow up wasn’t appropriate because people would die due to the infections. Surgery wasn’t appropriate because not everyone needed it. In the end we settled on either/or. Next step — what were we comparing it to? We decided on clinic exam of the senior surgeon. Based on that assessment the liklihood of a senior surgeon identifing pus in the neck when it was truly present was 50%. In other words, they would have been as accurate if they flipped a coin. I took a lot of heat presenting this data at international conferences (and still do) but CT’s are now standard procedures in deep neck infections.
To have a reasonable discussion about the accuracy of diagnostics means that the reader needs to understand how the pre-test probability affects the accurancy of the test, how the risk of over or undercalling affects the design (positive and negative predictive values) of the test and the means by which the test is studied. Accuracy of diagnostics (whether clinical exam, blood test or an MRI) deserves deep study but the design of the investigations is difficult and highly technical. It also varies from test to test so there are literally a million arguments to be made.
The discussion about error in diagnosis is so much more complicated than medication errors. A medication error is a discrete endpoint; yes/no. All diagnostics are less than 100% accurate. Readers need to know that a test may be inaccurate intentionally so that no one with disease is missed. Maybe your next post should start with the Users’ Guide to the Medical Literature (Diagnosis) found at
http://www.cche.net/usersguides/main.asp
then we can really get this discussion going!
http://www.waittimes.blogspot.com
Dr. S.H. Your June 6th idea seems, to me, to have substantial merit. Perhaps we should retain those, (6%), who acknowledge that they consider themselves in the lower half in the medical profession. Think of all the lives that will be saved and the number of accurate diagnoses that will be generated.
justapatient
Another great topic, thanks Maggie. My husband’s first major complication during his hospitalization was the result of a diagnostic error. The criticial issue in our circumstance was no physician actually viewed the diagnostic test (ultrasound) with their own eyes, they relied on a written report from the radiology department to intrepret the ultrasound, make their diagnosis and determine the course of treatment, which proved nearly fatal. (Due to my persistance after one week one doctor DID finally view the now week-old ultrasound with his own eyes. New diagnosis and course of treatment changed immediately to emergency surgery.)
I’ve often wondered what, if any, mechansim was in place at this facility (I suspect none) to learn from this and correct it for the future.
It boils down to the same root cause of all medical errors; total communication breakdown and history doomed to repeat itself because nobody is learning from near-misses or needless deaths. To the engineer, I agree with you, human’s are only human and everybody makes mistakes. I wasn’t angry about this, either, I was grateful somebody finally listened. But do we accept the same “ooops” will continue to repeat itself? Can the medical community recognize the difference between human error and carelessness or lack of adequate checks and balances, procedures, etc? Mainly I wanted to comment on the post about the opportunity for error that exists before the doctor ever gets those tests results. What are the lab/radiology procedures? Are films/blood tests et al viewed and interpreted by only one person, or double-checked? What kind of shifts to they work? What type of education/training is required? Etc. At one point I heard a growing trend was to outsource diagnostic tests to foreign countries…in other words, send your biopsy to India to have it tested and the report/results are sent to the doctor from this outsourced location. Anybody know if this is true or not?
How Doctors Think Can Affect Diagnoses (an excellent piece)
http://www.newyorker.com/reporting/2007/01/29/070129fa_fact_groopman
Maggie,
I’ve lived in this misdiagnosis world for four years now, and yours is the most objective piece I have read on the subject.
I, myself, was horribly, heinously misdiagnosed in the summer of 2004 — after a biopsy, told I had a rare, aggressive lymphoma (SPTCL) and would be dead within months if I didn’t begin chemo immediately. In trying to find any other treatment solution, I figured out instead that I had no cancer at all. I then fought with the oncologist who resisted my wish to get a second opinion, and my biopsy ended up at the NIH where my conclusion was confirmed — no cancer.
I may not be a medical professional, but I still get to say my piece about misdiagnosis, lousy communications, arrogance, and the way doctors are taught to think.
What I rarely find aligned are the concepts of “it’s all in your head” with a missed diagnosis. I hear from patients consistently that their doctors (who, as you have pointed out, have simply failed to listen because they are already stuck in their own heads) dismiss them, or provide a placebo of some sort. While I’m sure a few of these patients truly do have some sort of somatoform disorder, most truly are sick — and can’t get their doctors to think differently or more creatively or outside their little thinking boxes. Those, then, too, are MISSED diagnoses.
I’ve been a victim of the arrogance that too often accompanies the diagnosis process when a dead end is reached. I have lived it, and suffered from it, and frankly, were it not for my own stubborn refusal to give up on my findings, I might be dead.
As a result, I’ve changed careers. Now I try to teach patients how to communicate better, expect more, and partner with their doctors, despite the constraints on everyone.
It’s not easy. But in my experience, it can certainly be the difference between life and death.
Trisha Torrey
EveryPatientsAdvocate.com
and
http://patients.About.com
The post seems to suggest that cognitive dissonance accounts for most to all cases of misdiagnoses, and fails to acknowledge the time constraints put on physicians. A typical primary care physician operating on a full schedule, will see at least 100 patients in a 40 hour work week…in my experience closer to 125. This leaves maybe 15 to 20 minutes for each patient for the physician to gather data, review labs, and consider all possible diagnoses, assuming the doctor skips lunch every day.
I’d expect a bigger correlation exists between misdiagnosis and volume of patients seen.
Also, Trisha Torrey’s comments seem to suggest that every complaint warrants close medical scrutiny, and by definition more studies. This certainly runs counter to the themes usually expressed on this blog. Actually, many patients will present to a primary care doctor with benign symptoms of life…fatigue, aches and pains, etc…I would never tell this patient this was “all in your head”, but certainly I don’t think they all warrant a battery of testing. In fact, perhaps the incorrect diagnosis of lymphoma resulted from an imaging study and a biopsy that never needed to be performed in the first place, when reassurance and no further treatment would have been superior.
Sher, HoppyCalif, Ian, Bill, Lisa, Gregory, Trisha, Jon—
Thank you all for your comments –and welcome! to new names.
(By the numbers we get on viewers, I know that there are an enormous number of people who read the blog and don’t comment–which is fine. It’s great knowing you’re out there.
But it’s also nice when some of you pop up on the Comments threads.)
Sher–
You’re right; for various reasons, patients don’t always give doctors the “clues” that would lead to a correct diagnosis.
And medicine is terribly complex-as complicated as the human mind/body it addresses.
But there are ways that
we could reduce–though never, ever eliminate–misdiagnosis. I’ll talk about this in part 2.
HoppyCalif–
Good to hear from you on this blog. . .
“God is not available as a physican of choice”–great line.
My father also died as a result of medical error–a dye was injected and he was allergic to it. This had happened before with the same dye–and it was in the records at the hospital. So they should have known he was allergic to it.
But he also was in very bad shape–paralyzed from the waist down as a result of a stroke, and several other severe problems.
The hospital acknowledged what had happened; and neither my mother nor I even considered suing.
On the other hand, things like this don’t just happen to elderly patients who are enduring a poor quality of life. They also happen to healthy nine-year-olds.
In those cases, most parents would find it impossible to accept that
doctors are human and mistakes happen–it would take a long time to make your peace with an accident like that.
If something like that happened to my child, I would insist on a full investigation of how it happpened–and I would want the hospital to show me what they had done to try to make it unlikely that the same thing would ever happen to another child.
I don’t blame individual doctors or nurses for making errors (unless it’s a consistent pattern). We’re all fallible. But I do blame hospital boards that invest in hotel-like amenties ahead of investing in patient safety. (You all know how I feel about the waterfalls!)
And there are ways to
reduce cognitive errors and
misdiagnosis that I’ll talk about in Part 2.
Ian —
I agree that misdiagnosis is, far and away, the most complicated medical error. And there are literally millions of arguments to be made.
I also think that tests that are designed “so that no one with disease is missed” also are dangerous.
Inevitably, they lead to over-diagnosis and “disease mongering” which also hurts patients.
Thanks much for the link–I’ll look into it.
Bill–
There is something to be said for humility.
I think greater humility might be taught in med school–and to residents–by presenting them with hypothetical cases (based on records),
asking them to make a diagnosis and to say how certain they are. And then to tell the whole class the degree to which a high level of certainty accompanies misdiagnosis.
(No need to reveal names. The very certain people who misdiagnosed would know who they were. If they
wound up on this list repeatedly, it should cause them to reflect . .)
Lisa–
You wrote:
“It boils down to the same root cause of all medical errors; total communication breakdown and history doomed to repeat itself because nobody is learning from near-misses or needless deaths. To the engineer, I agree with you, human’s are only human and everybody makes mistakes. I wasn’t angry about this, either, I was grateful somebody finally listened. But do we accept the same “ooops” will continue to repeat itself? Can the medical community recognize the difference between human error and carelessness or lack of adequate checks and balances, procedures, etc”
These are all very good points. Better systems and better co-ordination of care can provide better guards against the inevitable human errors.
On outsourcing tests–Yes, this is happening. I
don’t find it especially worrisome if tests are outsourced to, say, India–the level of technical expertise there is very high. And the work ethic is, I think, as high as it is here.
Greg– Thank you for the link to the Groopman article. I like him almost as much as I like Dr. Atul Gwande, who also writes for the New Yorker. Gwande is such a wonderful writer’s writer . .
EVERYONE–anyone interested in this subject should take a look at the link Gregory has provided to a New Yorker article on diagnosis. I think you’ll like it.
Trisha–
Anytime a doctor becomes angry or resists the idea that you want a second opinion–I think that really is a warning sign that his arrogance might get in the way of your health.
If I were a doctor, and I had a patient who I thought was seriously ill, I would appreciate that second opinion to either back me up–or to serve as a warning that I should go back and look at the evidence again. He might be right. He might not. But I’d want to know what he had to say.
This is why I think that
large group practices are such a good thing. When you’re not certain, you can consult with colleagues.
Sounds like you’re doing good work.
Jon–
I agree that the rushed environment must contribute greatly to misdiagnosis.
Especially when it comes to listening to the patient’s story–asking the questions you need to ask to make that story more articlate–that takes time.
Tomorrow, I’ll be posting about how “stories” can be as important as the data that tests produce.
There is a solution to this: primary care physicians and others who practice “cognitive medicine” (listening to and talking to the patient) do need to be paid more so that they can spend more time with each patient.
I don’t think that they (or anyone, for that matter) needs to make $400,000 or $500,000 a year.
If someone does, I don’t begrudge them–I just don’t think we need to restructure our health care system to make sure that happen.
But the fact that primary care physicians graduate from med school with several hundred thousand in debt and then make only about $110,000 to $125,000 explains why they have to see so many patients each day.
The fact that there are so few of them (because it’s hard to make it finanically) is another reason why their schedules are so crowded.
And avearge of thirty minutes would seem to me a much more reasonable amount of time for a primary care visit— some visits with regular patients who have a realtively minor problem could be much shorter, but some need to be much longer.
I have a truly wonderful dentist who schedules one patient per hour. He’s in his mid-fifties and says that he has always practiced that way. He’s a
very kind, competent, and relaxed man.
The atmosphere in his office is so calm. When you go in, there’s no one in the waiting room. When you leave, there’s just one person–his next patient.
I’m not sure how the economics work for him. He’s expensive, but no more expensive than other very good Manhattan dentists. I suspect that the key to his success is that, once a patient discovers him, you stay with him for 30, 40 years . . . .
And he’s probably not concerned about earning a fortune. Rather than living in Manhattan, he lives in the country, spends a lot of time gardening, etc.
Maggie, Thanks for the response.
I’m just a little less optimistic that more reimbursement would have a big immediate impact, or that there is enough incentive for primary care to lobby for this. A minority of family physicians are in solo practice or have some form of ownership in their practice. More than half of graduates since 1994 are in either a multispecialty practice or are employees of a hospital or corporation.( http://www.jabfm.org/cgi/content/abstract/19/4/404). These physicians have little incentive to push for more reimbursement beyond giving the issue lip service, because they still indirectly benefit from overpaid specialty care. And as far as the employment model goes, in many cases I suspect the employer (corporation or hospitl) has a lot of input into how much time its employees (physicians) spend with their patients.
So more reimbursement may not necessarily translate into better outcomes in the employment model, which by far is the prevailing model for newer graduates. Any reimbursement reform would have to be accompanied by a number of changes which make “hanging a shingle” more feasible for new primary care doctors. (reforming byzantine credentialing processes, tax breaks for new start-ups, etc.) Most new grads have to accept employment positions, there are just way too many barriers to going out on your own beyond inadequate CMS reimbursement.
Jon
The URL I posted is no longer active. I base my claim on The following article:
1. Ringdahl E, et.al, Changing practice Patterns of Family Medicine Graduates: A Comparison of Alumni Surveys from 1998 to 2004, J Am Board Fam Med, 2006 Jul-Aug;19(4):404-12.
Sorry to go so far off topic. Thanks again for the blog and your comments.
Maggie,
A very interesting post, but the topic is certainly not a new concern for patient’s, providers or payors. Misdiagnosis and its consequences (and they are not always bad but sometimes fortuitous)have been around since medicine was first practiced. Even the new vogue of evidenced- based medicine is not immune. One of my most memmorable lectures as a first day medical student considered the above question. He was a stately looking man. After his greeting he surprised us with, “Everyone of you no matter what specialty you enter, will through acts of omission or commission kill another human being. Those of you who cannot face this reality should leave right now”. So much for “do no harm”. We all looked around the room, no one got up and left. My colleges and I didn’t discuss his statement much, we were much to busy learning how to heal the sick and save the dying. I mentioned this physician’s statement to an older physician at the time and asked him was he right and how did he know this for a fact. He smiled and asked if I could control the wind or stop an earthquake? I replied of course not, I’d be lucky just to stay out of their way. Precisely, he answered, the forces you’ll be fighting and the people you’ll be treating are much more destructive and more unpredictable then any wind or earthquake. Just do your best and you’ll keep the collateral damage to a minimum.
Overly confident about our skills maybe or just humble in the face of overwhelming odds and ashamed to admit it.
Jamessd-
Interesting, that’s the second time on this post I’ve heard someone from the medical community compare medical errors to acts of God. “Acts of ommission or commission” are not the same as controlling wind or earthquakes. This type of thinking is exactly where complacency and arrogance comes from.
very interesting and helpful. while the case for helping docs do a better job is obvious, wonder whether a dose of transparency would help patients individually while putting pressure on reform. what I found new and interesting here is that some types of misdiagnoses are much more common than others. it would be nice to know as a patient that in the case of my particular diagnosis, evidence suggested doc got it wrong X% of the time, which could be a signal on the import of a second opinion.
Lisa,
Your reaction to the post is one I am well acquainted with and it has nothing to do with with my or my colleges complacency and arrogance. The last time I checked, God had nothing to do with it. It has evrything to do with control or at least the perception of control. Health care is one of the most Sisyphean tasks humans engage in. The forces we struggle against were here before Man and will remain when we are long gone. They don’t care what you want or think. They certainly don’t care that you have a need to feel you are in control or what you feel your entitled to. They don’t care what my talents are or how arrogant I am. They don’t even care if they loss an individual battle because they have all the time in the world and will win the war. (the vast majority of us will become one of the 25% that consumes 80% of the healthcare dollars and there is nothing you can do about it but try to make it cheaper). I and my family are well aware of the consequences and anger when one of your own suffers a misdiagnosis. With 15 doctors in the family we have been on both ends of misdiagnosing and of being misdiagnosed, but I can assure you it was not from arrogance and certainly not complacency. I submit to you that nothing is more arrogant or complacent then using consumerism as a basis for a health care system. The enemy just doesn’t care, but I’ll continue to roll the rock anyway.
Jamesmd 10:57 AM
Aye.
Jon, James, Lisa, Jim —
Thanks for the comments.
Jon–There is pretty good evidence that if fees and salaries for “thinking medicine”
(primary care, family docs, pediatricians, gerontologists and palliative care specailists)were higher,
more medical students would pick these specialties. If you have $300,000 in loans, are 32, and want to buy a house and start a family, it’s hard to pick a specialty where you’ll be earning $110,000 a year.
I’m not thinking in terms of raising wages so that family docs can set up solo practices. The days of the solo practioner are over, both for economic reasons (overhead too expensive) and because 21st century medicine is, and needs to be, a team sport.
No one can know everything they need to know–even in a single specialty. Doctors need to be looking over each others’ shoulder, all looking at the same patient chart (as they do at Mayo and the VA) and collaborating.
So the model of doctors on salary seems to me fine–it’s just that the salaries need to be higher for those practicing cognitive medicine, and lower for some specialists that are practicing the most aggressive, expensive medicine.
Jamesd–
Of course misdiagnosis is not a new concern–but it is the type of medical error that is least dicussed, for the reasons
described in this post–and because most doctors have no way of knowing how many diagnostic erors they make–as described in the second post.
I do believe that in most specialties, a good doctor is bound to seriously harm or kill one or more patients over the course of a career. This knowledge must be a terrible burden, always somewhere in the back of your mind.
One reason I like Dr. Atul Gawande (author of Complicatons) so much is that he faces this fact with a combination of humility and sanity.
So I agree with virtually everything you’re saying. Though I would suggest that the instructor who said “just do your best and you’ll keep the collateral damage to a minium” sounds somewhat complacent–or perhaps cavalier. AT the same time, I can understand that this is a defense mechanism.
But I’d rather he said “Just keep on learning–don’t grieve over your mistakes, but always admit to them and study them.”
Lisa–I understand why the
“wind and earthquake” language conjured up images of the physician as god. But especailly after reading James second post, I think he meant it in the larger context of the doctor’s uphill battle:
“All flesh is grass.” We all die. And no doctor can ever “rescue” any of us from that fate.
Jamesd– That said (see my reply to Lisa above) I do think that hospitals need to pay more attention to (and put more money into) patient safety, and that health advocates like Lisa can help make that happen.
Here, I don’t see doctors as the problem. I think that hospital CEOs and hospital boards need to understand that rather than pouring money into a bigger cath lab (so that they can do more sometimes unncessary angioplasties) they should spend money on tryng to create systems that will block as many human errors as possible (here I’m thinking of Don Berwick’s work at IHI).
Rather than spending money on “hotel-like amenities” hospitals should do their very best to have an adequate number of nurses, to invest in the healthcare IT that make medication mix-ups less likely, and to invest in palliative care.
Letting a patient die in severe pain is also a “medical error” and, by all reports, it happens far too often.
I, too, intensely dislike “consumer-driven medicine” a la Regina Herzlinger.
But I do think medicine should be “patient-centered” in the sense that the whole point of the exercise should be keeping pain and suffering to a minimum.
Jim– A very good point, and one I hadn’t thought of. You’re right–it would be helpful to know where errors are most common in order to know when you should go for a second opinion.
Unless its an emergency, a second opinion strikes me as a good idea before virtually any operation.
More on diagnostic errors
I have been writing about the importance of accurate diagnosis throughout the 6+ years of this blog’s existence. I frequently opine that the quality movement has ignored diagnostic accuracy because it is not easily measured.
Maggie Mahar tries to a
This test can be performed anytime, irrespective of whether the patient is suffering from a herpes outbreak or not. The blood sample collected from the patient’s body is analyzed for the presence of HSV antibodies.
So, You Want To Be A Doctor…..
Lately in the media, others have said and appear to express concern about the apparent shortage of primary care doctors, in particular.
Typically, the main reason stated and speculated for this decline of the apex of our health care system is lack of pay of this specialty and few others when compared with other specialties chosen by potential physicians while in training.
Yet considering the additional attention of shortages of students in some medical schools as well, one may ask the question as to whether or not people want to be any type of doctor in the first place in the United States. About one third of their lives are spent achieving the requirements of this profession. Reasons for not choosing to enter this profession are several and valid and include the following:
There is the issue of long hours- with primary care in particular because of the apparent lack of doctors of this specialty. Such doctors may be over-worked without an expected pay reflecting the work they do.
Furthermore, those doctors employed by health care systems are required to see a certain number of patients a day, and receive a monetary bonus if this expectation is exceeded. It seems that most doctors are members of such health care systems. So burnout never anticipated certainly may occur. And I consider such a requirement mandated by health care systems demeaning to this profession, and leave the doctor without the control that the doctor is entitled to due to their training and experience, and this competes with the other adversary of doctors, which is managed care.
However, the recent increases in hospitalists, who are those doctors that are usually Internal Medicine doctors who specialize in patients presently under hospital care, and they have lessened the load for all doctor specialties for the work they do that the admitting doctors would have to do without their presence. This in itself makes a doctor possibly more effective and efficient in their practice outside of the medical institution.
All doctors, I presume, face a high degree of emotional and physical stress associated with their profession, as stated in the previous paragraph, for example.
And this is not to mention the incredible stress associated with patient care in the first place, with some patient cases causing more stress than others. Patient care is a noble and great responsibility.
Doctors, due to the changes that have occurred recently in the U.S. health care system, not only have the issue of money to deal with, but also a loss of autonomy regarding patient care combined with loss of respect that may be due in large part to the others previously mentioned who dictate how they practice medicine. Ironically and often, these others who direct these doctors are not as qualified as the doctor in the first place. This is complicated by the perception that the public, with some who view doctors as having the easy life with their pay and profession, which does not seem to be the case presently.
There are also reasons of malpractice insurance, which is why doctors choose to join health care systems, it is believed, to pick up the tab for this necessity, along with eliminating the concerns of running a practice in a private manner, which historically has been the case, as their offices are owned by the health care system as well. Yet having another pay their malpractice premium does not eliminate their concern about being sued for error perceived by one of their patients. To protect against this, defensive medicine is implemented by doctors, which basically involves copious amounts of documentation regarding the doctor’s adherence to recommendations and guidelines.
Up to 90 percent of malpractice cases against a doctor are baseless and without merit, so they are unsuccessful for the plaintiff, yet this still affects the rate the doctor or another system has to pay for malpractice insurance of a wrongfully accused doctor. This is combined with the amount the doctor has to spend to defend themselves in such cases, which separates them from their focus on the restoration of the health of their patients completely. Furthermore, malpractice lawsuits cost about 100,000 dollars over the course of about 4 years for such cases. A tort reform in Texas in 2004 resulted in annual malpractice premiums reduced by about a third of what they were. Soon afterwards, claims against doctors remarkably dropped by about 50 percent. Some specialties of doctors pay more premiums for malpractice than others.
For example, OB/GYN doctors have been known to pay around 300 thousand dollars a year for this insurance. Certain types of surgeons experience a similar high rate of malpractice premiums. Malpractice flaws are catalysts for doctors to practice the inappropriate defensive medicine mentioned earlier to avoid potential litigation, which is a waste of health care resources with ordering unneeded patient methods or procedures to cover themselves against such lawsuits.
Also, about a third of the U.S. is insured by Medicare, which progressively has lowered what they will reimburse a doctor for regarding the care they give a patient they treat. This fact is recognized by other insurance companies who will eventually follow the recommendations of Medicare, usually, regarding the reimbursement issue, so it seems. This will lead to a doctor having to see even more patients in order to make it financially with their profession, as this has resulted in the overall income of a doctor experiencing a decline of about 10 percent over the last decade or so.
Further complicating the financial state of a primary care doctors is that doctors normally have to pay off the debt acquired from attending medical school and training, which averages well over 100,000 dollars today after their training is completed. About 20 years ago, that debt was only about a fifth of what it is today. Paying this debt off is typically about 2 thousand dollars a month that doctors on average is what the doctors choose to pay in order to eliminate this debt in a timely fashion.
There are some who believe that doctors in the U.S. are over-paid. This may be true, but they are not absent of financial concerns as with any other profession. And as mentioned earlier, clearly doctors accept more responsibility involved with human health than other vocations, so this should be kept in mind perhaps more by others.
Most doctors do not recommend their profession to others for such reasons stated in this article so far presently, and perhaps other reasons not mentioned. This is somewhat understandable, yet extremely unfortunate for the health of the public in the future, especially. There have been cases where doctors do in fact change careers, and get into vocational fields such as medical communications or corporate medical companies. Also, expert witnessing is another consideration for those who choose to leave their profession. Finally, other choices considered include consulting and research. The training of doctors fortunately leaves them with options not involved directly with the flaws of medical care, but this is bad for us as citizens, overall. The etiology of their departure from their designed profession is largely due to the negative state of mind that occurs, which is expressed in apathy, cynicism, and vexation.
Conversely, not all doctors are deities. Like others, some are greedy and corrupt, which complicates others in this profession. Personally, I believe that the intentions of most physicians are bonafide. Yet in time, due to the nature of the current health care system, doctors frequently and really do become cynical, demoralized and apathetic.
This may be considered a significant concern to the well-being of those in need of restoration of their health, understandably.
Not long ago, the medical profession that has been discussed had overt honor and a clear element of nobility. Such traits are not as visible or recognized anymore, which saddens many intimate with the profession and importance of public health that is needed by many.
“In nothing do men more nearly approach the Gods then in giving health to men.” — Cicero
Dan Abshear
Author’s note: What has been written has been based upon information and belief.
Dan–
I appreciate the passion of your comment and agree with some of what you say.
But “belief” is not quite the same thing as “infomration” — and “knowledge”is better than both.
Often “belief” is just the conventional wisdom, which, all too often, is wrong.
You write: “Up to 90 percent of malpractice cases against a doctor are baseless and without merit”
This simply isn’t true.
Please see two posts I’ve written on malpractice here
(http://www.healthbeatblog.org/2008/05/medical-malpr-1.html) and here (http://www.healthbeatblog.org/2008/05/medical-malprac.html)
MISDIAGNOSIS, Tragedy of medical profession
Amalgam Dental Fillings = Mercury Poisoning
Dear Bob,
A huge percentage of the population has been misdiagnosed and labeled with a plethora of illnesses including from autoimmune , neurological, mental and endocrine diseases. Unfortunately, the medical profession has not be taught about the adverse effects of chronic exposure to mercury from amalgam dental fillings. Amalgam fillings are 50% mercury, a known neurotoxin, which is released from commonly used silver amalgam fillings for the duration of the filling in the tooth. It is inhaled and ingested and has the potential of disrupting every organ and function in the body. Mercury is a hazardous risk to health and he environmental, and is being removed from medical devices (vaccines included) and various other products due to health and environmental risk. Dental fillings are no different, in fact, the World Health Organization concluded in 1991 and again in 2005 that mercury from dental fillings is the largest exposure of mercury to humankind.(Mercury Policy Report and graph available).
I am one of millions who was misdiagnosed by several neurologists when I was suddenly struck with double vision and diagnosed with Multiple Sclerosis, Lupus and then Myasthenia Gravis in 1998. I was told that I would be sick for the rest of my life, that steroids would fix my eyes, and that there was no known etiology for these diseases. Understanding that one does not develop MS in a day, I was determined to find out what had caused the “autoimmune” symptoms. Within five days of research I discovered that I had been poisoned by mercury during a dental procedure seven days prior to the
onset of symptoms. I had had an old amalgam filling removed and a new one placed.
The doctors misdiagnosed me, labeling me with MS, Lupus and Myasthenia Gravis all life threatening diseases. If I had followed these recommendations, I would have been sick for the balance of my life and most probably n a wheel chair by now. Instead, I had my fillings removed slowly by a mercury-free dentist, changed my diet, took hundreds of nutritional supplements and recovered. My story can be read at: http://www.toxicteeth.org.
The crime is that the dental profession has not been honest with the medical profession, about the dangers of mercury fillings and the doctors are not taught about the effects of mercury exposure from dental fillings. At a 2006 FDA Scientific Panel Review of the dangers of mercury fillings, Dr. Lyn Goldman pediatrician and an environmental epidemiologist.at John Hopkins Bloomberg School of Medicine testified:
DR. GOLDMAN: Yes. I mean, I think it’s important to understand, in terms of the way the clinical world has looked at this issue, that I mean, I’ve been involved in a number of exercises to come up with just environmental history questions for physicians to use, and triggered by different indications, and most of us were taught, I was certainly taught that exposure to mercury from amalgam is minimal, and that one shouldn’t think about mercury toxicity from amalgam.
I have never included a question about recent dentistry on an environmental exposure questionnaire that I’ve worked on. It’s never been suggested.
Now I will have to say there is something-I was recognizing this, and I appreciate your asking that question, because [U1]there is something that’s happened in the last couple of days in these discussions, to kind of at least move me a little bit further over into being a little more concerned than I was before, and I will tell you the two things that concern me.
One is that some of these exposure data, the range of exposures then–and there is a lot of new science, even though the white paper kind of implies there’s not. But then it uses the studies, and there are a lot of new studies that do show, that do document an association between, you know, amalgam and levels of mercury in urine, and more than I would expect, given what I was taught. And I’m sure that that’s true for the others who were taught what I was taught, because we were all taught that at one point.
And so I’m taking it more seriously, that there could be exposures, A. Two, that there could be acute exposures and that there could be symptoms associated with that, and that maybe it is worth inquiring about whether there’s symptoms. We haven’t done that inquiry, and I just took a quick look at PubMed, just to see, you know, if someone’s published on that question, and there are no publications, other than, you know, the Kingman study included a question about tremor in the questionnaire, and that’s about it.
You know. So I think this is an area where I don’t think we can make a conclusion based on the literature, you know, it’s kind of silent, but I will say on an indirect basis, I am more concerned about this today than I was last week. Whatever that means.
[U2]
This entire passage articulates the lack of awareness by the medical professionals to consider dental amalgam” mercury” related effects. This is very telling considering Dr Goldman’s professional history, including work at the EPA. She is in a leading university medical school and reveals that dental amalgam exposure is not factored into consideration. Just how damaging is ADA propaganda re safety in dental amalgam? The proximate cause of injury might be considered the reliance on erroneous data in order to protect egregious egos.
I commend you for bringing the issue of “misdiagnosis” to the attention of the medical profession and the general public.
For more information on the symptoms and illnesses related to mercury toxicity:
http://www.iaomt.org, http://www.toxicteeth.org, http://www.amalgam.org.
Sincerely,
Freya Koss
Pennsylvania
frekoss@aol.com
Awesome information you have here. Thanks for sharing.