A developing discipline aims to find ways to measure efficient accuracy and diagnostic prowess, just as we now scrutinize core measures and surgical outcomes.
Last month's shocker that a robustly healthy long-time friend had just been diagnosed with an awful cancer has devastated me. The discovery of his illness came so late that it allowed him just a few weeks to prepare for his death.
Distracted and irritable, I hid behind life's minutiae to deny what was actually happening. I told myself the poor prognosis was exaggerated. After the inevitable had been confirmed and I had had a good cry, it prompted the question we all ask ourselves when terrible stuff like this happens.
Why didn't his doctors catch this sooner?
Maybe the clinicians' bet was on another culprit that fit this patient's youthful profile more conveniently. Perhaps there was a failure to order the right test. Could a test result have been interpreted incorrectly?
There might have been lack of follow up on the part of a doctor, a nurse, or even a clerical error. Or maybe the patient didn't accurately relate symptoms soon enough or thought they would all go away.
A Different Kind of Medical Error
Who knows what should have happened differently, if anything. Or even if a quicker catch would have prevented an early death. Maybe my friend's illness just sped out of control before anyone could do anything.
Though lawyers might seize on such cases to assign monetary blame, healthcare professionals don't usually think of delayed diagnoses as medical errors in the same class as wrong-site surgeries or a preventable infections.
Unless there's an egregious lapse—like an obvious lesion on an MRI that no one noticed—providers move on, and chalk it up to other things: symptom complexity, a sudden surge of evil biochemistry, or something outside the understandable limits of today's physician knowledge.
But if a growing group of physicians and researchers has its way, that attitude will soon change, and there are signs that it already has. There must be a way to measure this gap in care based on an emerging field of science, they say. This developing discipline will find ways to measure efficient accuracy and diagnostic prowess, just as we now scrutinize core measures or surgical outcomes.
Ready for Prime Time?
Hardeep Singh, MD, is a champion of the push to raise misdiagnoses to the realm of quantifiable preventable error. "Fortunately, our field is beginning to attract the attention that we have long hoped for," he wrote in an editorial entitled "Diagnostic Errors: moving beyond no respect and getting ready for prime time," in a October supplement to the British Medical Journal Quality & Safety, which published 10 related articles devoted to the topic.
In an interview this week, Singh, chief of Health Policy, Quality and Informatics at the Houston's Veterans Affairs Center for Innovations in Quality, thinks we're still pretty much in the dark about the extent of the problem, or even how to differentiate a missed diagnostic opportunity from a delayed diagnosis from an outright incorrect conclusion, which may set the patient on an unnecessary and harmful treatment path.
High Rates of Misdiagnoses
However it's defined, some studies put the number of missed or incorrect diagnoses at between 10% and 15%, depending on the specialty, he says. Autopsies see diagnostic discrepancies between 10% and 20% of the time, and half of the pediatricians answering a large survey said that they misdiagnose between once and twice each month. Radiologists get it wrong 2% of the time, he says.
But those are all guesses. Primary care settings, clinics, and emergency departments represent the lion's share of misdiagnoses, often because of system miscommunication, Singh says.
"You're getting lots of tests done at the same time, blood, X-rays and CT, and they're delivered across multiple systems and settings that aren't always communicating with other. It's fragmented, and the diagnostic process becomes much more vulnerable in that setting."
But Singh, who is also an associate professor at Baylor College of Medicine, is extremely optimistic that providers are ready to acknowledge all this and take this problem head on. They need to define what exactly they mean by a misdiagnosis or "missed opportunity," and zero in on the most likely causes.
7 Reasons Diagnostic Errors are Gaining Attention
Singh gave me a quick rundown of why diagnostic error detection and prevention might finally be getting more respect:
1. Incentives. The creation of ACOs and other forms of shared savings programs will reward clinicians who achieve correct diagnoses with minimal use of expensive testing and specialty referrals. Primary providers may order tests for the most likely or potentially the most serious medical problems first.
2. Greater focus and financial support. Only six years ago, a small group of research physicians interested in the topic formed a group they called Diagnostic Errors in Medicine to begin annual conferences on the topic. That has evolved into the formation of the Society to Improve Diagnosis in Medicine (SIDM) to more formally amass like-minded physicians, researchers and educators in research projects and work on gaining consensus on terminology. The group now receives financial support from the federal Agency for Healthcare Research and Quality.
3. Advocacy. The American Medical Association's Center for Patient Safety has made diagnostic error a key part of its agenda and is advocating more research on the topic.
4. High-profile cases. Medical errors of many other types have drawn media attention. In 2001, 18- month-old Josie King died from narcotics overdose and dehydration at Johns Hopkins in Baltimore, and in 1994, award-winning columnist for the Boston Globe, Betsy Lehman, died of a chemotherapy overdose at Dana Farber Cancer Institute in Boston.
But last year, diagnostic error detection and prevention got its own symbolic patient in 12-year-old Rory Staunton. Doctors at NYU Langone Medical Center's emergency department told Rory's parents that he was suffering from a minor bellyache, and sent him home. Three days later he died from septic shock from an infection the hospital's teams failed to see. The story made the New York Times' front page.
Singh says that other such cases are being reported by media organizations, giving misdiagnosis the political clout it needs to ascend to a higher priority on the safety and quality agenda. "More patients and their families are now getting involved," he says.
5. Powerful interested parties. The United Kingdom has launched a special initiative focused on improving timeliness of cancer diagnoses, inspired partially by anecdotal reports from a decade or so ago of lethal delays in certain diagnostic procedures. And the Institute of Medicine may soon assign a task force to write a special report on the extent and cause, as well as the ramifications, of diagnostic error.
6. Gap alerts. The growth of electronic medical records and health information technology may give vendors opportunities to embed gap alerts or alarms indicating when certain follow-up tests or notifications have not taken place as they write software updates. An unintended 20-pound weight loss in one month, for example, would prompt an alarm.
7. Team decision-making. Since diagnostic errors might be attributed to private practice clinicians making decisions by themselves, perhaps in a partial vacuum, which Singh says may be influenced by "heuristics, biases, overconfidence," team decision-making or consults may become more routine, especially when rarer and more serious illness are under discussion.
Singh acknowledges that the misdiagnosis area of quality measurement "still has a very long way to go." And it must compete for attention with much more obvious, acute healthcare-acquired conditions such as infections, medication errors, and surgical mishaps, especially those with obvious links to poor outcomes such as mortality.
The extent of the problem, which nearly everyone in healthcare quietly acknowledges is serious and widespread, must be quantified and systematically parsed to find the biggest weak gaps so they can be closed.
Doctors get it wrong 10% of the time. If that truly is the case, it's healthcare's dirty little secret.