A colleague recently asked me to opine on the diagnostic error problem. As you might imagine, once I start, it is difficult for me to slow down. Here are some of my somewhat disjointed thoughts.
1. Diagnostic accuracy, while the most important quality measure for internists (and many other physicians), likely will not occupy the primary focus of performance measurement. The problem stems from our inability to accurately identify diagnostic errors. Some have likened the diagnostic error problem to Supreme Court Justice Potter Stewart's famous quote about pornography, “But I know it when I see it”
2. We have systems that increase diagnostic errors. As I understand our emergency department admission system, most patients have to have a presumed diagnosis for admission. Quality assurance makes decisions about length of stay based on a presumed diagnosis. Once a patient has a diagnostic label, we have to make an effort to not let the admission label influence our thinking. Thus …
3. We have a responsibility to not take any previous diagnosis as set in concrete. When patients get admitted to our service, I assume that everyone else is wrong until we have data to prove otherwise. This attitude does not represent arrogance, but rather skepticism. This approach means that we question every diagnosis, the new diagnoses and the old diagnoses. We ask whether the diagnosis has support in the story, the exam and the testing.
4. As an academic hospitalist, I probably have more time to focus on diagnosis than most practicing physicians. The diagnostic process takes time, and most physicians have a time shortage. We cannot keep asking physicians to see patients in shorter time aliquots than the patient deserves.
5. While some diagnostic errors stem from system problems, I believe most come from diagnostic laziness. I am guilty of laziness, as are my colleagues. We miss diagnoses when we fail to go through a rigorous analysis. We forget to switch from system 1 thinking to system 2 thinking. We minimize the importance of a finding that does not fit our diagnosis.
Diagnostic accuracy is the most important function of being a good internist (in my opinion). I suspect it is true in other specialties, but I cannot speak for them. When we make an accurate diagnosis, we have a much better opportunity to help the patient. While that seems obvious, most performance measurement fails to consider the diagnostic accuracy, but rather only the treatment of the presumed diagnosis.
db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.