Most of the time a medical diagnosis is on point. But misdiagnoses do occur, and an overly confident doctor may be partly to blame, a new review suggests.
The rate of diagnostic error is as high as 15%, Eta S. Berner, EdD, and Mark L. Graber, MD, write in a special edition of The American Journal of Medicine dedicated to understanding and addressing diagnostic errors.
Physician overconfidence and a lack of feedback following a diagnosis are two important contributors to the problem, they note.
"When directly questioned, many clinicians find it inconceivable that their own error rate could be as high as the literature demonstrates," Berner and Graber write. "They acknowledge that diagnostic error exists, but believe the rate is very low, and that any errors are made by others who are less skillful or less careful."
Berner says it is often the cases physicians perceive as routine and unchallenging that end up being misdiagnosed.
"With the hard cases, doctors generally seek out different opinions or turn to (computer-based) decision support tools," she tells WebMD.
A Missed Diagnosis
Retired engineer Paul Mongerson is all too aware of the problem of medical misdiagnosis, and he has spent the last 28 years addressing the issue.
In 1980, Mongerson was incorrectly told by four different doctors that he had pancreatic cancer, a highly deadly cancer that kills most people who have it within five years.
Mongerson made up a matrix charting his symptoms and test results to help him assess the probability that his doctors were right.
"I determined from that matrix that I didn't have cancer," he tells WebMD.
Just two days before he was scheduled for cancer surgery, a fifth doctor agreed and Mongerson canceled the operation.
"I said at the time that if I survived I was going to see what I could do to help other people," he says.
What Mongerson did was form a foundation to fund the development of computer-based programs designed to assist physicians in diagnosing disease.
While such programs are being used in many hospital and educational settings, they are not yet widely used by private practice physicians.
Mongerson says performing more autopsies and having systems in place to crosscheck medical diagnoses would help address the issue of lack of feedback.
Barriers to Patient Follow-up
In one of the newly published essays, Gordon D. Schiff, MD, of Chicago's Cook County Hospital addressed the barriers to the follow-up of patients in the real-world, clinical practice setting.
Not surprisingly, lack of time was at the top of his list, followed by fragmentation of care, the large number of symptoms for which there is no clear diagnosis, cost and managed care barriers, and physician defensiveness about critical feedback from peers.
"Learning and feedback are inseparable," Schiff writes. "The old tools (used by physicians) — individual idiosyncratic systems to track patients, reliance on human memory, and patient adherence to or initiating of follow-up appointments — are too unreliable to be depended upon to ensure high quality in modern diagnosis."
He calls for a systematic approach to link diagnoses with patient outcomes.
In a different essay, Mark Graber, MD, of the department of medicine at State University of New York at Stony Brook and VA Medical Center in Northport, N.Y., proposes new roles for patients that can help. One is to have the patient become a "watchdog for cognitive errors" by having doctors communicate to patients more about what diagnoses they are considering rather than just telling patients what tests to get or what medications to take. Sharing more information with patients can help patients be more active in checking for errors.
A second role is as a "watchdog for system-related errors" to help keep track of their own medical information such as test results and medication lists. By doing so, "the patient can play a valuable role in combating errors related to latent flaws in our healthcare systems and practices," Graber writes.
Berner adds that patients can help by questioning their doctors carefully during the diagnostic process, and, especially, letting them know when they might have made the wrong call.
"If your doctor says you should be better in a week, and you aren't, call the office and let them know," she says, adding that a surprising number of patients do not do this.
Patients who aren't sure about their diagnosis should also ask their doctors what else their condition might be, she says.
The simple suggestion was a major focus of the best-selling 2007 book How Doctors Think by Harvard Medical School physician Jerome Groopman.
In it Groopman writes that instead of being intimidated by their doctors, patients should ask questions like, "Is there anything that doesn't fit your diagnosis?" and "Is it possible that I may have more than one problem?"
Mongerson tells WebMD that the point is not to put physicians on the defensive, but to explore all medical possibilities.
"After everything I went through I am still very high on doctors," he tells WebMD. "They are very dedicated people who work very hard and go through hell when they find out they have made a mistake. The problem is, they don't normally find out."
SOURCES:
Berner, E.S. The American Journal of Medicine, supplemental issue, May 2008; vol 121.
Eta S. Berner, EdD, professor, department of health services administration, University of Alabama at Birmingham.
Gordon D. Schiff, MD, Cook County Hospital, Chicago.
Paul Mongerson, retired engineer; founder, Paul Mongerson Foundation, Naples, Fla.
Groopman, J. How Doctors Think, Houghton Mifflin, 2007.
Graber, M. The American Journal of Medicine, supplemental issue, May 2008, vol 121.
Reviewed by Dr. Ramaz Mitaishvili
