Blog | Wednesday, October 28, 2015

Some thoughts on diagnostic errors


The Institute of Medicine released a new report, ‘Countless' Patients Harmed by Wrong or Delayed Diagnoses

We will read many opinions on the problem. Readers know that I have a great interest in this problem. I have thought about it often, and talk about it frequently. Here are a few tweetable thoughts.
1. Allow patient admissions without a diagnosis. Insisting the emergency department label the patient w/ a diagnosis often leads to anchoring heuristic which can lead to errors.
2. Receiving physicians (either consultants or hospitalists or outpatient physicians) must be skeptical of any diagnosis.
3. If the patient's course does not follow the textbook, you are likely reading the wrong page.
4. Teach learners to flirt with, even sleep with, but be certain before they marry a diagnosis (h/t Dr. Lourdes Corman).
5. When you feel confused, start again from the beginning, retake the history, redo the physical exam, and review the old records and the lab data.
6. Allow the responsible physician to delete incorrect diagnoses from the medical record.
7. Above all else, we must remain skeptical every day.

I remember prior to starting medical school hearing the phrase “great diagnostician.” During medical school I continued to have role models who championed the diagnostic process.

The IOM report focused on diagnostic errors, but we should also focus on the road to diagnostic excellence. Many diagnoses are straightforward and simple but some require time and thinking. Here are some more thoughts about how we get to diagnostic excellence and what interferes.
1. Many difficult diagnoses require time to think. Unfortunately, our payment system does not encourage spending more time on the diagnostic process.
2. The first clue to a diagnostic conundrum is the presence of a red flag or the absence of expected findings.
3. Diagnostic excellence requires deliberate practice. We must learn from every diagnostic conundrum, the ones we get correct and the ones we miss.
4. When we have to rush, we order tests rather than take a careful history and the history provides major clues most of the time.
5. We receive no rewards for correct diagnoses yet the patient often suffers from incorrect diagnoses.

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 as 2 parts here and here at his blog, db's Medical Rants.