“Missed, wrong, and delayed diagnoses have been underappreciated by internal peer review, autopsy reports, and examination of malpractice claims.” That is according to a new report published in JAMA Internal Medicine, led by Dr. Hardeep Singh, of the Houston VA Health Services Research and Development Center of Excellence.
Researchers examined electronic health records from a large, urban VA and a large private health system. In 190 cases, a total of 68 unique diagnoses were missed. Most missed diagnoses were common conditions in primary care, with pneumonia (6.7%), decompensated congestive heart failure (5.7%), acute renal failure (5.3%), cancer (primary) (5.3%), and urinary tract infection or pyelonephritis (4.8%) being most common. According to the authors:
There were marked differences in the most common missed diagnoses across the 2 sites, largely because their local contexts and patient and practitioner populations were markedly different. For instance, practitioners at site A were predominantly internists who cared for older veterans (who generally have more comorbidities), whereas at site B, family practitioners cared for an overall younger population. However, at both sites, the most common process breakdowns arose within the patient-practitioner encounter.
“We have every reason to believe that diagnostic errors are a major, major public health problem,” said Dr. David Newman-Toker of Johns Hopkins University School of Medicine in Baltimore, in an interview with Reuters Health. “You’re really talking about at least 150,000 people per year, deaths or disabilities that are resulting from this problem.”
The take-away from this report, unfortunately, will be “doctors miss diagnosis in patient.” However, it’s not that simple. As Dr. Newman-Toker explained in a commentary on the new study, medical diagnosis is extremely difficult:
Diagnosing can be messy, and scientific understanding is imperfect. Decisions must be made with limited time and information under conditions of uncertainty, often with inadequate experience or expertise in diagnosing a given symptom or disease. Consistent patient follow-up with feedback on diagnostic performance is usually lacking or biased away from detecting diagnostic errors, creating a serious barrier to ongoing skills improvement.
There is a tendency today to claim that all health care related problems can be solved by the implementation of an electronic records system. This study, however, suggests that all of the fancy technologies available today are not an adequate substitute for a thorough diagnostic exam. And that goes for the patient too:
In approximately one-third of cases, patients presented with symptoms that appeared to be unrelated to the missed diagnosis, which could easily divert the practitioner’s attention during the short span of the primary care visit.
Most of the errors found in this study were related to the patient-practitioner clinical encounter; specifically information gathered during the medical history and physical exam. Recent reports have also documented a long-known problem of the medical-history: patients lie. The Wall Street Journal recently reported that:
28% of patients surveyed acknowledged sometimes lying to their health-care provider or omitting information. But the health-care providers surveyed suspected worse: 77% said that one-fourth or more of their patients omitted facts or lied, and 28% estimated it was half or more of their patients.
So what’s the solution? According to the authors of the JAMA study, “preventive interventions must focus on common contributory factors, particularly those that influence the effectiveness of data gathering and synthesis in the patient-practitioner encounter.”