Diagnostic Errors ~ More common than you think

A recent Institute of Medicine (IOM) report warns that most Americans will experience a “meaningful diagnostic error” at least once in their lifetime—sometimes leading to “devastating consequences”. While good metrics on diagnostic errors have yet to be developed, the report estimated that diagnostic errors:

• Affect 5% of US adults seeking outpatient care every year;
• Account for 6 to 17% of adverse events in hospitals; and
• Contribute to 10% of patient deaths.

Modern medicine is complex—with scientific advances in molecular diagnostics leading towards ever more personalized and precision-based medicine. It seems almost counter-intuitive that the diagnostic process can be as fallible as it appears; the report reinforces the view that we each need to be able partners with our doctors to reduce the likelihood of diagnostic errors.

What constitutes a diagnostic error? The IOM Committee that produced the report defines a diagnostic error as “the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient.” An error can occur if a patient receives a diagnosis that differs from what he/she has (or does not have) or when it is incomplete or imprecise.

The IOM’s recommendations to reduce diagnostic errors include improving teamwork between patients, their families and health care providers. Specifically, the report suggests engaging patients through their electronic medical records (EHRs) that include clinical notes and test results, and by creating environments in which patients participate in the diagnostic process and freely provide feedback and concerns. This starts with helping patients understand the diagnostic process.

While, technically, the diagnostic process begins when a patient reports a health concern to his/her health care professional (a nurse practitioner, a nurse or a doctor), for the patient, the process needs to start, mentally, when they notice something out of the ordinary. In today’s world, this may lead to online searches of symptoms and/or a telemedicine appointment. Buyer beware: it is important to note that “Dr. Google” may always be “in”, but may not necessarily always be right. Know which resources are reliable as you do your online research, and remember that your doctor is the expert in medicine—keep an open mind as you explore the diagnostic possibilities with him or her.

So, before setting up that telemedicine appointment, heading to the nearest urgent care clinic, or seeing your doctor, a patient should take stock: what are the symptoms, where are they located, why do they seem different and of concern? This means for the patient: be the expert in yourself; know what is normal and what is not. Jot down a few notes regarding onset, frequency and impact. Know your medical history. Write out questions and prioritize them so you address the most important elements for the diagnostic process first. When you head to that appointment, whether online or in person, make sure you can articulate all these details to the doctor.

As a patient, be aware that doctors are often operating under tight time frames—and, anxious to get to a diagnosis, they may interrupt your narrative before you are done. If you can, gently steer the doctor back to your narrative until you have completed the highlights. (Doctor, before answering that question, may I add a couple of things here?) And, in a world increasingly consumed by data (lab tests, wearables, imaging, etc.) there is no substitute for the physical exam. Listening to the patient, and conducting a proper exam, should be integral to the diagnostic process in most non-emergent cases.

If your doctor seems overly absorbed with filling out electronic medical forms and assigning codes, skips or provides only a cursory exam, and/or jumps to conclusions before hearing you out—well, you may want to find a different doctor. The Malcom Gladwell “Blink” moment can be dangerous to your health.

Equally dangerous: the doctor who orders every test in the book—a practice commonly called “defensive medicine”. In our litigious world, it is hard to blame a doctor for ordering more tests than necessary—though if they are affiliated with the lab, it may be something they also get reimbursed for in the extant “fee for service” payment system. Will that battery of tests lead to the right diagnosis? Ask the doctor what he/she is hoping to rule in or rule out with the tests that are ordered.

The additional hurdle for many patients: doctors were taught “When you hear hoofbeats, think horses and not zebras.” Should you have something that is less common but with symptoms that overlap those of more common diagnoses, building mutual respect will help reduce the likelihood of a misdiagnosis or a missed diagnosis. If your doctor recognizes that you know yourself pretty well, and that you are a responsible patient, the chances that they will dismiss concerns are smaller. Again, be proactive as the expert in you: if a doctor does not directly address your medical issues, is dismissive (or worse), then find yourself another doctor. It is your health at stake here—not theirs.