1/31/16: CLINICAL PRACTICE: We’ll All Be Misdiagnosed in Lifetime, Reports Institute of Medicine; I Agree

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“All of us,” the Institute of Medicine concluded recently, “will likely experience a meaningful diagnostic error in our lifetime.” This error, reports the IOM, may have “devastating consequences.”

This is hardly news to me or to anyone else who has extensively navigated the U.S. healthcare system and seen firsthand the breakdowns in the diagnostic process. The potential for error is tremendous; its realization, profound. My mother almost died because of poor diagnostic reasoning and a refusal by physicians to reexamine their analyses and conclusions.

For more than a year the IOM’s Committee on Diagnostic Error in Health Care studied “the best evidence” available in the literature and from experts on a range of topics having to do with diagnostic process and error and patient experience and safety, and concluded that not only are diagnostic errors widespread, they “have been largely unappreciated within the quality and patient safety movements in healthcare.”

“Without a dedicated focus on improving diagnosis,” the committee projected in its “Improving Diagnosis in Health Care” report, which was released last September, “these errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity.” (The IOM is a nonprofit, nongovernmental organization under the auspices of the National Academy of Science.)

In “Our Parents in Crisis,” I devote a lengthy chapter to the how-to and how-not-to of diagnosis and return to this skill, art, process, etc., time and time again. It’s a pervasive problem. Many failings in the healthcare milieu impede the achievement of a correct diagnosis, including biases and lapses in critical thinking among physicians.

I’m pleased to say that my Chapter Four, “DoctorThink & No-Think: Psyching Out Misdiagnoses,” tracks the IOM’s report quite well, and it’s much shorter and easier to read. The report confirms my own observations, experiences, and research, the latter of which overlaps the sources upon which the Committee on Diagnostic Error relies. I agree with its bottom line:

“Improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative.”

The report also gave me an entrée into a diagnostic phenomenon that I’ve encountered, but had not seen named before, that of overdiagnosis.

Overtesting, especially with medical imaging (e.g., X-rays, CT scans), creates overdiagnosis, which surgeon/writer Atul Gawande defines in his 2015 New Yorker article, “Overkill,” as “the correct diagnosis of a disease that is never going to bother you in your lifetime.” It’s an incidental finding that physicians unnecessarily treat. More about this, below.

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According to the IOM’s independent committee, which was comprised of 21 members of the National Academy of Sciences:

“Diagnostic errors—inaccurate or delayed diagnoses—persist throughout all settings of care and continue to harm an unacceptable number of patients. For example:

1) “A conservative estimate found that 5 percent of U.S. adults who seek outpatient care each year experience a diagnostic error [My research suggests the percentage is far greater; ER outpatient followup typically does not occur.];

2) “Postmortem examination research spanning decades has show that diagnostic errors contribute to approximately 10 percent of patient deaths [My research agrees, but these data are limited because only 5 percent of all people who die today are autopsied, down from a high of 60 percent in the 1950s and 30-40 percent in the 1960s.]

3) “Medical record reviews suggest that diagnostic errors account for 6 to 17 percent of hospital adverse events;

4) “Diagnostic errors are the leading type of paid medical malpractice claims, are almost twice as likely to have resulted in the patient’s death compared to other claims, and represent the highest proportion of total payments.”

I commend the IOM’s comprehensive report to you. You can download it for free at http://iom.nationalacademies.org/Reports/2015/Improving-Diagnosis-in-Healthcare.aspx.

The IOM committee identifies eight goals to improve diagnosis and reduce error and offers many recommendations on how to implement them. There is no quick or easy fix, but healthcare educators and other medical professionals need to start chipping away. Among the eight goals, the ones upon which I focused most in my book are:

“Facilitate more effective teamwork in the diagnostic process among health care professionals, patients and their families.”

Respectful, open, and honest communication among all interested parties is a must that only occurs now when you encounter a physician who is willing to acknowledge his/her fallibility and appreciates that patients and their advocates can contribute meaningfully to the diagnostic process. What patients and families relate is telltale, and physicians who understand how important listening is know this. The IOM report also recognizes that all consulting specialists, including radiologists and pathologists, need to be an active part of the diagnostic team. Often in a diagnostic crisis with one of my parents, I wanted to meet and hear from the behind-the-scenes radiologists, whose imaging interpretations usually determine the examining physicians’ treatment decisions.

The advantages to teamwork are many, not the least of which is that one person cannot know all diagnoses. “Pattern recognition,” which is a fast, automatic, nonanalytical process by which a doctor take a patient’s symptoms and fits them into a disease pattern he/she knows well, gets a diagnostician only so far. Some symptoms elude patternization. Headaches, for example, are not always migraines in a patient with a history of migraines.

The IOM committee also points out that advances in biology and medicine have “outstripped human capacity to apply” new knowledge. The ninth edition of the International Classification of Diseases, it notes,lists about 13,000 diseases, with new ones being added every year. To keep up in their field, according to the report, “primary care clinicians would need to read for an estimate 627.5 hours per month.” Needless to say, such advances have led to “a deluge of innovations in diagnostic testing.” Physicians may not even be aware of some tests and, therefore, not think to order them.

“Enhance health care professional education and training in the diagnostic process.”

Amen. The medical schools have their work cut out for them. I think law school, which I’ve attended, trains better critical thinkers. Too much of medicine is rote memorization. Clinical problem-solving certainly requires a command of basic knowledge, but that’s only the beginning in diagnosis. One has to know how to apply it.

“[T]he lack of focus on developing clinical reasoning and understanding the cognitive contributions to decision making,” the IOM committee states, “represents a major gap in education within all health care professions.”

Cognitive errors in the clinical reasoning process, including biases and predispositions to think in a way that leads to judgment failures, also can hijack diagnosis. The widely recognized “overconfidence bias,” for example, can encourage physicians to diagnose a disease based on incomplete information because they’re convinced their opinion is correct. (See Dr. No-Think.)

“Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance.”

If there are no safeguards within an individual healthcare-work system and its culture to prevent diagnostic mistakes and to learn from mistakes when they occur, then the mistakes inevitably will be repeated. The emphasis needs to be on improving outcomes, not on assigning fault or blame for poor outcomes. There must be independent, objective oversight.

In my view, every family-patient advocate has to be an amateur diagnostician, to ensure that his/her loved one receives appropriate care and treatment in a timely fashion. The IOM committee agrees that “patients are central to the solution” of the diagnostic error problem and defines an error from the patient’s viewpoint as “the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient.”

I strongly support improved doctor-patient-family communications and collaboration.

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The IOM committee describes overdiagnosis as “a serious problem in health care today, [that contributes] to increased health care costs, overtreatment, and the associated risks and harms from this treatment.”

Overdiagnosis occurs “when a condition is diagnosed that would otherwise not go on to cause symptoms or death.” In the process of undergoing the excessive testing that leads to overdiagnosis, patients may be exposed to a lot of ionized radiation.

I remember my frustration when I would read a litany of non-prioritized diagnoses in my deteriorating father’s primary-care medical records. I would think, “Suppose we knock out all of the ones that won’t kill him. What are we left with?”

I also wondered at times about Dad’s radiation exposure. He declined CT scans during hospitalizations when he thought it was appropriate to do so, but he still underwent more than I thought were necessary and, perhaps, healthy.

According to the IOM report, “Epidemiological studies have found reasonable, though not definitive, evidence that exposure to ionizing radiation (organ doses ranging from 5 to 125 millisieverts) results in a very small but statistically significant increase in cancer risk.” Children are more “radiosensitive” than adults, and the risk increases with cumulative radiation exposure. [Emphasis on “not definitive.”]

Studies cited in the report purportedly have shown that 20 to 40 percent of all CT scans could be eliminated without compromising patient care.

I plan to explore overdiagnosis and the cancer risk of radiation further. I’ll let you know what I find out.

Ann, 1/31/16

 

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