Medical Confessional Highlights Doctors' Diagnostic Errors

Additionally, understanding why people think in certain ways is key to understanding diagnosis error, said Croskerry. By undoing certain biases in thinking, one might be able to think more clearly and perhaps come up with a more accurate diagnosis. But this task is easier said than done.

"The problem is it's extremely difficult to de-bias people," said Croskerry. "Generally speaking, trying to change the way that people think is a very challenging task." He recommended addressing physician thinking biases in medical school.

"Not Yet Diagnosed" may be better for patient

Another way of thinking that has become ingrained in most physicians is the idea that an overconfident, perhaps wrong diagnosis is better than not diagnosing a patient at all. Most patients don't appreciate when their physicians don't seem decisive about a diagnosis, and historically, physicians have been more successful when they confidently make a diagnosis, said Croskerry. Additionally, physicians validate their ability to make diagnoses when they are confident.

"Physicians tend to place a lot of faith in their own diagnoses—most physicians think it's the most important skill that they have," said Croskerry. "It's a lot easier, if you give the patient wrong medication, to admit to something like that than to actually admit to your thinking processes having gone astray. People take that far more personally."

Once a diagnosis is made, many other decisions concerning medical care are then made based off of it, said Croskerry. Further thinking about what else the diagnosis could possibly be tends to stop. Assigning a "Not Yet Diagnosed" or "NYD" label to a patient whose symptoms don't lead to a specific, certain diagnosis may ultimately help the physician ascertain the true cause of an illness—by thinking further on what the patient might have. Croskerry has seen success in Canada with this technique.

Both Schiff and Croskerry agreed that more emphasis should be placed on physicians admitting to their patients uncertainty about diagnosis and that more work needs to be done at an earlier stage, perhaps in medical school, to introduce the idea of feeling comfortable with uncertainty to physicians. Additionally, Schiff said the question of physicians admitting a diagnosis error is first and foremost about a patient safety culture.

"This idea about patient safety culture—creating a system where people can honestly look at errors in a blame-free way, learning from mistakes and improving from those, rather than covering them up or having to defend them—is so central for us learning," said Schiff.

Technology: a double edged sword

Technology has allowed the medical profession to make better decisions as far as diagnoses go. Clinical decision support and electronic medical records offer places where some progress has been made, and more will likely be seen in the future, although one disadvantage of computerized decision-making is its inability to read the context of a doctor/patient interaction, said Croskerry.

Medical tests, however, are an area where the "ball" is often dropped with diagnoses, said Schiff. Instead of physicians making a diagnosis and ordering tests to confirm, the reverse often happens.

"We are now short-circuiting the diagnostic process and going right to diagnostic tests," said Schiff. "The questions is, 'Is this a step forward or a step backward?' These are powerful new modalities to hopefully make us do better with diagnosis, but they also introduce all sorts of problems from ordering the right tests, to harming people with these modalities (the radiation from repeated x-rays)."

Schiff also said it's important for physicians to ensure they are using the tests properly, interpreting the results correctly, and following up with patients to measure if the course of treatment based on a test was the best one.

Heather Comak is a Managing Editor at HCPro, Inc., where she is the editor of the monthly publication Briefings on Patient Safety, as well as patient safety-related books and audio conferences. She is also is the Assistant Director of the Association for Healthcare Accreditation Professionals. Contact Heather by e-mailing hcomak@hcpro.com.

Cheryl Clark is a senior editor and California correspondent for HealthLeaders Media Online. She can be reached at cclark@healthleadersmedia.com.