This is the first of a two-part series examining medical errors. This article addresses thought processes hospitalists use that may lead to mistaken diagnoses. Part 2 will look at what healthcare corporations are doing to improve diagnoses and reduce errors.
When talking about tough diagnoses, academic hospitalist David Feinbloom, MD, recalls the story of a female patient seen by his hospitalist group whose diagnosis took some time to nail down.
This woman had been in and out of the hospital for several years with nonspecific abdominal pain and intermittent diarrhea. She had been seen by numerous doctors and tested extensively. Increasingly her doctors concluded that there was some psychiatric overlay—she was depressed or somatic.
“Patients like these are very common and often end up on the hospitalist service,” says Dr. Feinbloom, who works at Beth Israel Deaconess Medical Center in Boston.
But to Joseph Li, MD, director of the hospital medicine program at Beth Israel, this patient seemed normal. There was something about the symptoms she described that reminded him of a patient he had seen who had been diagnosed with a metastatic neuroendocrine tumor.
Although this patient’s past MRI had been negative, Dr. Li remembered that if you don’t perform the right MRI protocol, you’ll miss something. He asked the team to obtain a panel looking for specific markers and to repeat the MRI with the correct protocol. It was accepted as fact that there was no pathology to explain her symptoms but that she had had every test. He requested another gastrointestinal (GI) consult.
“It seemed so far out there, and then everything he said was completely correct,” says Dr. Feinbloom. “She had Zollinger-Ellison syndrome.”
Clues from Sherlock
In his book How Doctors Think, Jerome Groopman, MD, discusses Sir Arthur Conan Doyle, physician and creator of the brilliant detective Sherlock Holmes. When it comes to solving crimes, Holmes’ superior observation and logic, intellectual prowess, and pristine reasoning help him observe and interpret the most obscure and arcane clues. He is, in the end, a consummate diagnostician.
One of the first rules a great diagnostician must follow is to not get boxed into one way of thinking, says Dr. Groopman, the Dina and Raphael Recanati chair of medicine at the Harvard Medical School and chief of experimental medicine at the Beth Israel Deaconess Medical Center, Boston. That is one of the downsides of a too-easy attachment to using clinical practice guidelines, he says.
“Guidelines are valuable reference points, but in order to use a guideline effectively, you have to have the correct diagnosis,” he says. “Studies over decades with hospitalized patients show that the misdiagnosis rate is at least 15% and hasn’t changed.1 A great deal of effort needs to be put into improving our accuracy in making diagnoses.”
Compared with other kinds of medical errors, diagnostic errors have not gotten a great deal of attention. The hospital patient safety movement has been more focused on preventing medication errors, surgical errors, handoff communications, nosocomial infections, falls, and blood clots.2 There have been few studies pertaining exclusively to diagnostic errors—but the topic is gaining headway.3
Think about Thinking
Diagnostic errors are usually multifactorial in origin and typically involve system-related and individual factors. The systems-based piece includes environmental and organizational factors. Medical researchers conclude the majority of diagnostic errors arise from flaws in physician thinking, not technical mistakes.
Cognitive errors involve instances where knowledge, data gathering, data processing, or verification (such as by lab testing) are faulty. Improving diagnostics will require better accountability by institutions and individuals. To do the latter, experts say, physicians would do well to familiarize themselves with their diagnostic weaknesses.