Research shows that the majority of medical diagnoses are correct. However, diagnostic errors occur more often than patients expect and certainly more than doctors realize. In fact, the rate of diagnostic error can be as high as 15 percent, according to Eta S. Berner, EdD, professor of health administration in the School of Health Professions at UAB.
Berner and her colleague, Mark L. Graber, MD, FACP of the Veterans Affairs Medical Center in Northport, N.Y., wrote the lead paper for a compilation of articles on the issue, appearing as a supplement to the May 2008 issue of The American Journal of Medicine.
“The sensitive issue of diagnostic error is rarely discussed and has been understudied,” Berner said. “The papers in this volume confirm the extent of diagnostic errors and suggest improvement will best come by developing systems to provide physicians with better feedback on their own errors. Given that physicians overall are dedicated and well-intentioned, we believe that if they were more aware of these factors and their own predisposition to error, they would adopt behaviors that would help decrease the likelihood of diagnostic error.”
The Paul Mongerson Foundation sponsored the supplement. As a patient 28 years ago, Mongerson received a misdiagnosis, having been told by four different doctors that he had pancreatic cancer. He developed a matrix of his symptoms and test results, from which he determined that he didn’t have cancer. A fifth doctor agreed, and Mongerson’s cancer surgery was canceled. Today, his foundation promotes computer-based analysis and other strategies to reduce diagnostic errors.
“In my view, diagnostic error will be reduced only if physicians have a more realistic understanding of the amount of diagnostic errors they make,” Mongerson said. “I believe that the accuracy of diagnosis can be best improved by informing physicians of the extent of their own errors and urging them to take steps to reduce their errors.”
In compiling the paper regarding misdiagnoses, Berner discovered that one of the underlying causes is physician overconfidence. “Research shows that physicians typically generate hypotheses almost immediately upon hearing a patient’s initial symptom presentation,” she said. “Even if more exploration is needed, the most likely information sought is that which confirms the initial hypothesis, often without full exploration of other possibilities.”
Patients report that diagnostic errors are a serious concern. Berner and Graber summarize a survey of patients, 35 percent of whom reported that they or their family member had experienced a medical mistake, about half of which were described as misdiagnoses. Berner says providing feedback to physicians can serve to make diagnostic error more visible, and timely feedback can mitigate the harm that an initial misdiagnosis might have caused.
“Feedback is an essential element in developing expertise. It confirms strengths and identifies weaknesses, guiding the way to improved performance,” Berner said. “Given our current health system, however, in many settings there’s often no feedback on patients after they’re treated. For example, an emergency room doctor may make a diagnosis and send the patient home and may never find out the patient’s outcome.”
Berner is working on a study to address the feedback issue. “I want to see if we can develop a system that will provide the needed feedback,” she said. “We want to see if it’s cost-effective and quality effective, and see if it will be supported by the patients and their physicians.”
The timing of feedback is important, Berner adds. “Immediate feedback is effective, delayed feedback less so. This is particularly problematic for diagnostic feedback in real clinical settings. Currently, the gold standard for feedback regarding diagnostic errors is the autopsy, which of course can only provide retrospective diagnostic feedback.”
Berner and Graber recently co-directed the first national conference focusing on diagnostic errors in medicine. The objective of the conference was to summarize the current state of the field and to look at different approaches to reducing diagnostic errors. The conference was successful and provided the first focused opportunity for members of the field to discuss the issue and suggest ways to solve the problem.
What should patients do until such a feedback system is put in place? “They can provide feedback to the doctor,” Berner said. “When the patients receive a diagnosis, they can ask what else it could be. If things don’t happen the way the doctor says they should, provide feedback so he can decide if he needs to change his original thought.”
July 2008
