Medical Misdiagnosis on Patient Safety Radar
Reprinted from UAB Synopsis, Vol. 27, No. 28, July 21, 2008
Physicians can become overconfident about the accuracy of their diagnoses because their failure rate is small and their errors may not be brought to their attention, says a UAB professor who is studying strategies to reduce the frequency of medical misdiagnoses.
Medical misdiagnosis is no longer under the patient safety radar, medical educator and health informatics researcher Eta S. Berner, EdD, says. She is coeditor of “Diagnostic Error: Is Overconfidence the Problem?” a supplement from the American Journal of Medicine (2008;121[Suppl 5A]) and cochair of the first national Conference on Diagnostic Error in Medicine held May 31 to June 1 in Phoenix, Arizona, in conjunction with the American Medical Informatics Association’s Spring Congress. The supplement is available online at http://www.amjmed.com/issues/contents?issue_key=S00029343(08)X0007-5.
Following the Institute of Medicine’s report To Err Is Human, which claimed 44,000 to 98,000 deaths nationwide resulted annually from medical errors, attention focused on wrong-limb amputations, surgi- cal sponges left in, and the like. Little attention was paid to medical misdiagnosis, which actually accounted for 17% of the adverse events cited in the report, Dr. Berner says.
In a comprehensive literature review included in the American Journal of Medicine (Am J Med) supplement, she and coeditor Mark L. Graber, MD, determined that the rate of medical misdiagnosis generally is higher than either patients or physicians believe, ranging from 5% to 15%, depending on specialty. Dr. Graber is chief, Medical Service, Veterans Affairs Medical Center, Northport, New York, and professor and associate chair, Department of Medicine, State University of New York, Stony Brook.
Physicians may recognize errors but tend to attribute higher error rates to other less skilled physicians, she says, and much of the discrepancy between perception and reality arises from the lack of feedback for the results of their diagnosis.The literature review covered the prevalence of diagnostic errors, the psychology behind misdiagnoses, general psychology literature on overconfidence, and decision-support systems.
The supplement and the symposium drew similar conclusions:
Physicians consistently underestimate their own rate of diagnostic errors;
Strong, direct, and timely feedback to physicians that potentially could induce change is lacking both from patients and from systems initiatives, so physicians often are not confronted strongly and directly with their diagnostic errors; and
Several potentially helpful medical decision-making products are available but frequently go unused.
Dr. Berner is engaged in a subsequent study through a grant to UAB from the federal Agency for Healthcare Research and Quality (AHRQ) to identify ways to elicit and automate feedback to physicians and to study how the feedback process affects costs, quality of care, physician reaction, and patient satisfaction. One arm of the study will look at how often an emergency department physician’s diagnosis winds up being changed later in the patient’s hospital stay and what systems might be put into place to furnish feedback to the physician about his or her initial diagnosis. The second arm is looking at ways to provide more timely feedback in the ambulatory care setting.
The Phoenix conference, cosponsored by AHRQ through another grant to UAB, was endorsed by the Institute for Health Care Improvement, the National Patient Safety Foundation, the Veterans Affairs National Center for Patient Safety, and the Center for Patient Safety Research and Practice at Brigham and Women’s Hospital in Boston, Massachusetts. Attendees came from the United States, Australia, Canada, Japan, and Europe.
“We know there’s not going to be an easy fix for this thorny problem. Medication alerts are a lot easier to address than medical misdiagnosis,” she says, “and it’s easier to get feedback in an institutional setting such as a hospital than in the outpatient setting. But the subject is gaining traction now, and it’s increasingly favored for research funding.”
Other articles in the Am J Med supplement provide an expanded model of fundamental feedback processes in diagnostic problem solving, highlighting particular leverage points for avoiding error; explicate the numerous barriers to adequate feedback and follow up in the real world of clinical practice; and emphasize the need for a systemic tracking approach over time that fully involves patients.
The review concluded that physicians overestimate the accuracy of their diagnoses and that overconfidence contributes to diagnostic error.
Drs. Berner and Graber conclude: “Physicians in general have well-developed metacognitive skills, and when they are uncertain about a case they typically devote extra time and attention to the problem and often request consultation from specialty experts. We believe many or most cognitive errors in diagnosis arise from the cases in which physicians feel certain about a diagnosis. These cases appear to present with routine problems that resemble similar cases that the clinician has seen in the past. In these situations, the metacognitive angst that exists in more challenging cases may not arise. Physicians may simply stop thinking about the case, predisposing them to the pitfalls that result from our ‘cognitive disposition to respond.’ They fail to consider other contexts or other diagnostic possibilities, and they fail to recognize the many inherent shortcomings that derive from heuristic thinking.”
The authors add: “Improving patient safety will ultimately require strategies that take into account … why diagnostic errors occur, how they can be prevented, and how the harm that results can be reduced.”
Dr. Berner joined UAB 22 years ago as associate director of the Office of Educational Development (OED). The OED, whose functions now reside in the Office of the Associate Dean for Medical Education, provides educational resources and consultation for faculty and students. Dr. Berner’s early research was in the area of medical problem solving. Research for her 1994 New England Journal of Medicine (330:1824-1825) article on computer diagnostics was funded by the National Library of Medicine and led her into the fields of computer-assisted problem solving, computerized decision-support systems, and health informatics.
Philanthropist Paul Mongerson, whose pancreatic cancer had been misdiagnosed, provided funding to UAB to support Dr. Berner’s research for the Am J Med literature review.