Missed diagnoses are harming or killing 150,000 patients every year. How can so many avoidable mistakes be happening?
Most of us go to a doctor or hospital because we are having a problem. If a symptom is causing us a great deal of discomfort or if it does not go away after a reasonable amount of time, chances are that good that we will want a health professional to figure out what’s wrong and come up with a treatment strategy that will help us recover.
Diagnosis is one of the most fundamental skills a medical student is supposed to master and then hone as a resident and practicing physician. We assume that all those arduous years of training have prepared doctors to figure out exactly why we are having symptoms. How well do they do at this essential task?
We were shocked to learn a few years ago that the answer to this crucial question is not very well. Even worse, it is a third rail issue. Researchers hare steered clear of this controversial topic. Professors in medical schools, hospital administrators and government regulators have pretty much ignored the problem. But in 2009 David Newman-Toker, MD, PhD and his colleague Peter Pronovost, MD, PhD, blew the lid off this scandal with a groundbreaking article in the Journal of the American Medical Association titled, “Diagnostic Errors–The Next Frontier for Patient Safety.”
In this research they revealed that “an estimated 40,000 to 80,000 US hospital deaths result from misdiagnosis annually.” During a radio interview with us they subsequently confided that the number published in JAMA was probably low and a more realistic figure was more likely 100,000 hospital deaths each year from missed diagnosis.
Keep in mind that these were missed diagnoses in hospitals. What about misdiagnosis in your doctor’s office? Until a week ago we had no good idea about diagnostic errors in a primary care setting. That all changed with an article published in JAMA Internal Medicine (online, Feb. 25, 2013). Until this study there was not much information about “Diagnostic errors (missed, delayed, or wrong diagnoses)” in a family practice clinic or internist’s office. Now we know the problem is worse than we imagined.
Researchers studied two large primary care practices. Site A was a large urban Veterans Affairs facility with 35 PCPs (primary care providers). Site B was a private health care system with 34 family medicine PCPs. By tracking electronic medical records the researchers were able to identify patients who saw a primary care provider and within two weeks either had to come back to the doctor’s office or go to an emergency room or be admitted to a hospital. They then analyzed the records of such patients to see if there had been a diagnostic error.
Of the 190 cases where diagnostic errors were discovered, most “had potential for moderate to severe harm.” Here are the some of the common missed diagnoses:
• Kidney failure
• Congestive heart failure
• Compression of the spinal cord
• Urinary tract infection
• Adverse drug effect
• Heart attack or severe heart problem
When such serious conditions are missed in a primary care setting they will be often be treated incorrectly and the outcome can be delayed recovery, severe complication or death.
According to an accompanying commentary by Drs. Newman-Toker and Makary, “more than 150,000 patients per year in the United States might have undergone misdiagnosis-related harm.”
Why? Why are there so many missed diagnoses? The researchers suggest that there are breakdowns in communication. Time pressure almost assuredly interferes with the process. Doctors are trained to make quick decisions based on obvious symptoms. Doing so can divert their attention from the actual cause of the problem. These researchers documented that there were serious flaws in history taking. Patients may not have gotten to tell their stories completely. And doctors did not connect the dots accurately. Moreover, doctors do not always communicate with each other well to make sure that data from tests are transmitted appropriately.
The real shocker in this study, though, was the lack of what is called a “differential diagnosis.” In 80% of the missed diagnoses, doctors failed to follow a time-honored medical practice of considering all the possibilities and prioritizing them appropriately until the correct diagnosis was reached.
Far too many patients are misdiagnosed, either in a doctor’s office or in the hospital. These mistakes lead to inappropriate treatment and that causes “serious harm, permanent damage, immediate or inevitable death.” The authors of the study call for “patient empowerment and engagement in the diagnostic process.” We couldn’t agree more.
In our book, Top Screwups Doctors Make and How to Avoid Them we have a list of questions to ask your doctor the next time you have a problem.
Top 10 Questions to Ask to Reduce Diagnostic Disasters:
1. What are my primary concerns and symptoms?
2. How confident are you about this diagnosis?
3. What further tests might be helpful to improve your confidence?
4. Will the test(s) you are proposing change the treatment plan in
5. Are there any findings or symptoms that don’t fit your diagnosis
or that contradict it?
6. What else could it be?
7. Can you facilitate a second opinion by providing me my medical
8. When should I expect to see my test results? Will you call with
them, or will they come by mail or electronically?
9. What resources can you recommend for me to learn more about
10. May I contact you by e-mail if my symptoms change or if I have
an important question? If so, what is your e-mail address?
You can learn more about how to avoid diagnostic mistakes in the book. We provide details about the Top 10 Reasons Why Doctors Screw up Diagnoses and give you the tools you need to prevent this from happening to you or someone you love. You will also find out more about the most commonly missed diagnoses so you can be prepared. Here is a link to more information about the book.
Here are some stories below about the implications of such errors from real people.
This came from J.L.B.
“Several years ago my wife had a bad case of bronchitis. Our family doctor put her on an antibiotic. She felt better for a few weeks and then she started coughing severely again. We went back to the family doctor who is a great person and competent doctor. He was going to put her on another kind of antibiotic. I am an accountant and as an analytical person I asked him a sensible question which was ‘Why is my wife coughing so much after going through a round of antibiotic. Shouldn’t some more tests or x-rays be taken?’
“He thought over my statement for a minute and then ordered a chest x-ray. What the x-ray revealed was that my wife had a mild case of pneumonia. There was some fluid in the bottom of her lungs which showed up on the x-ray. The doctor then ordered her to stay in bed for several days and prescribed another antibiotic. Bed rest is mandatory for pneumonia whereas a person can be up and on their feet if they have bronchitis.
“If he had not discovered that she had pneumonia, she would have been on her feet and getting worse and worse. After that event whenever we went to the doctor he would ask me if I had any questions. He had a new respect for my observations/comments. He had almost made a wrong diagnosis which could have resulted in very serious situation for my wife.”
“This happened many years ago and somehow I survived. I was having severe stomach pains which went around to the front and I was nauseous for days. I was about 20 years old and had been having “bouts” for the past couple of years on and off but with increased frequency.
“The military doctor I went to did not order any tests because he decided that I was just lonely for my new husband who was stationed in Japan. How did he come to that conclusion? He had a daughter who was lonely for her new husband as well.
Within a few months I went overseas and got pregnant. I had a daughter and fortunately had no attacks during my pregnancy. But within 3 months of giving birth I had such an attack that I literally had to crawl on my hands and knees to get help from a neighbor.
“It turns out that I had gall stones almost the size of golf balls and was extremely lucky that I had not had an attack during my pregnancy because both my baby and I could have died.”
“My 86-year-old father went to three specialists (cardiologist, internal medicine and pulmonologist) in November complaining of shortness of breath and fatigue. All three told him he was fine. The cardiologist, who had been treating Dad for an irregular heart beat, told my sister he was concerned Dad was showing signs of dementia. The internal medicine specialist prescribed an anti-depressant.
“He collapsed 10 days after seeing the pulmonologist, 20 days after seeing the cardiologist. The emergency room team said he had pneumonia and was almost at end stage congestive heart failure. He also had pneumonia. He died 10 days later.
“I wrote the doctors two weeks ago asking what tests they performed to determine he was fine. Haven’t heard back and am guessing I won’t.”
The stories above reinforce the research just published in JAMA Internal Medicine. Pneumonia and heart failure are frequently misdiagnosed. Don’t let it happen to those you care about. Be assertive! Ask about the “differential diagnosis” and make sure the doctor tells you what else might be causing your symptoms (besides the “obvious”).
We do not want you to become a statistic. Missed diagnosis is one of the more common causes of death in America, right up there with strokes and adverse drug reactions. It shouldn’t be. These are preventable errors. We hope you find our book helpful in avoiding medical mistakes.
Share your story below. We hope it will empower other patients so that they can take more control over their health.