Experience is making mistakes and learning from them. Bill Ackman
Diagnosis plays a central role in medicine, and getting it right is pivotal in helping the patient to get the appropriate care. Making a diagnosis is a complex exercise, because patients don’t come with labels saying I suffer from this condition or that one. There is probably no task more challenging for a doctor than making the correct diagnosis. The doctor needs to be a detective in order to figure out what’s wrong, and it’s because there is so much that we still have to learn about the human body, that diagnosis is still a very uncertain art. It takes considerable clinical acumen to make the right diagnosis, which is why one in every ten diagnoses is wrong. Diagnostic error is the leading cause of medical malpractice claims in the US, and is estimated to cause 40,000-80,000 deaths annually. It’s because misdiagnosis can do so much harm, that we need to ensure that the diagnostic process is timely, accurate, reliable, and efficient if we want to make medical care safe.
When do diagnostic errors occur?
A diagnostic error occurs when either the diagnosis is wrong, missed or delayed. The cause of diagnostic error is often multi-factorial, and it could be a result of cognitive errors, which are mistakes in the doctor’s thought process, perhaps because he is rushed; system errors, for example, because of a lack of communication, as a result of which an abnormal lab result is overlooked; and a combination of both. A diagnostic error is more closely associated with some specialties than others, such as radiology, geriatrics and emergency medicine. They are common in the ICU (Intensive Care Unit) as well, where patients have multiple complex problems. Interestingly, it is not only the rare disease that is the subject of diagnostic error; it is the misdiagnosis of common diseases such as heart attack, cancer and stroke which causes the most harm.
Doctors are taught to follow a disciplined process in order to make the right diagnosis. This involves collecting information from the patient by taking a history, doing a clinical examination, and ordering lab tests. The clinical data then needs to be analyzed and processed. The systematic method that doctors use to come to the right diagnosis is called differential diagnosis. The doctor makes a list of possible diagnoses in order of probability, and then tests the strength of each diagnosis by asking further detailed questions, ordering more tests, or referring the patient to specialists. A differential diagnosis checklist helps physicians avoid the most common cause of diagnostic error-failure to consider the correct diagnosis as a possibility. Ideally, a number of potential diagnoses will be ruled out as the investigation progresses, and only one will remain at the end. Of course, given the uncertain nature of medicine, this is not always the case. Technology can also aid doctors to help minimize diagnostic errors. Medical digital databases like Watson @ http://www.ibm.com/smarterplanet/us/en/ibmwatson/ and Isabel @ www.isabelhealthcare.com can be utilized intelligently to boost the doctor’s diagnostic accuracy, by serving as diagnosis support systems. They do not replace the doctor, but act as a safety net by reminding him to consider all possibilities, so he does not overlook a particular disease.
Why does misdiagnosis occur?
Since the doctor has to make the diagnosis, there are many ways in which he can err:
Most doctors know only the common diseases
-There is more than 20,000 human diseases, and most doctors don’t know about the rare ones, which is why these are often missed.
Different doctor skill levels
-Not all doctors are alike, and while a general practitioner is well versed in common diseases, a specialist would know a lot more about the rare diseases(in his specialty).
-All doctors are human and have biases. If they see a certain disease frequently, they tend to diagnose it frequently, and this might result in an error
Saving you money
-Some doctors will avoid tests, because they don’t want you to pay extra for tests which are not likely to be helpful. This works well for the majority, but can result in a misdiagnosis for the small percentage that might have a rare disease.
Lack of time
- It really is quite sad how little time a doctor will typically spend with a patient. In reality, doctors have to shoot from the hip; although they’ll hit the mark with most common diseases, they can get tricked by rarer conditions.
Some symptoms are hard to analyze
-Medicine can be complex and the human body can fool even the smartest doctors.
Laboratory tests and imaging studies
The various medical tests that are used to confirm or rule out diagnoses can also sometimes fail. They are useful tools, but are not perfect and the things that can go wrong are:
- Samples could get contaminated or mixed up, or the test procedure might be done improperly-for example, if the laboratory technician is unqualified, or the lab is poorly equipped. This can be a major problem in India, where quality control is often lacking.
False positives and false negatives
- A problem with all medical tests, no matter how well they are performed, is that they may give rise to false positives and false negatives. Let me False positives and false negatives- A problem with all medical tests, no matter how well clarify. False positives are test results which are abnormal (‘positive’), even though the patient has no disease. A false positive result causes needless anxiety, and will often lead to a situation in which the patient will have to undergo even more tests to prove or disprove the previous results. Conversely, test results which are normal (‘negative’), even though the patient does have the disease are called ‘false negatives’. These results could also cause problems, because they may induce a false sense of security, thereby leading to a delayed or missed diagnosis. Most tests have a wide range of normality, and can only very rarely yield a simple ‘yes’ or ‘no’ answer as to whether a patient has a particular disease or not.
-Many tests rely on the expertise of the doctor doing them-for example, the skill of the pathologist in analyzing the tissue biopsy he receives. Errors are rare, but they can occur. Thus, errors made by radiologists in interpreting scans fall into two groups:
• Perceptual errors (missing what is on the film)
• Cognitive errors (seeing what’s on the film, but failing to attach significance to it)
The ABCs of Misdiagnosis – How patients can help their doctor to make the right diagnosis
Poor quality labsThe unreliability of medical tests also poses a major problem for patient safety in India today. The most obvious reason can be attributed to laboratories whose functioning is marred by poor quality control, unskilled manpower and obsolete equipment. There is little ‘policing’ or retesting; this results in subpar standards.
After all, even a science graduate with a six-month diploma in laboratory technology can set up a medical lab today, if he so desires. Most people tend to rush to the nearest laboratory to get their tests done, but such haste can be a big mistake. After all, if the laboratory is not reliable, how can you trust its report? You should try and go to the best laboratory possible- your life can depend upon your test results!
PatientIt may seem unfair to hold a patient responsible for a wrong diagnosis, but what the patient does (or does not do) can contribute to a wrong diagnosis as well. This is how patients sometimes end up shooting themselves in the foot:
Self diagnosis-The most likely way for a patient to contribute to a misdiagnosis is attempting to diagnose themselves, without professional medical advice.
Not reporting symptoms-Sometimes patients don’t tell their doctor everything, either because they are embarrassed, or they feel that it’s minor, and not worth mentioning.
Failure to perform the ordered tests-In some cases, patients don’t get diagnostic tests done, even when a doctor has ordered these. This can occur due to oversight, financial constraints, complacency, laziness or embarrassment.
What can patients do to reduce diagnostic error and harm?
See a doctor- A majority of the diagnoses made by doctors are correct , and are far more likely to be accurate than your own. Never self-diagnose based on what you have read on the Internet, in books, or gathered from amateur advice. Doctors are trained to see signs that patients don’t.
See a specialist- A trained specialist is even less likely to make a wrong diagnosis than your family doctor.
Ask for a diagnosis- Ask your doctor to explicitly name his diagnosis. Sometimes the doctor may not be sure what the diagnosis is, and a good doctor will be willing to share this uncertainty with you. He can give you a list of his top three guesses, and then describe how he plans to eliminate them, one by one. Sometimes the doctor may not tell you what the name of the condition he suspects is, not because he wants to keep you in the dark, but perhaps because he doesn’t want to scare you with a serious sounding name. Other doctors feel that patients won’t understand the diagnosis anyway, while others assume that patients don’t want to know.
Ask questions- It is hard to assess the accuracy of your diagnosis unless you understand what it is, and the basis on which it was made. Exactly what is the diagnosis? How sure is your doctor? What are the other possibilities? What other diagnoses has your doctor ruled out? What other related diseases are possible? Which ones have been tested for or ruled out?
Dr Jerome Groopman, the author of How Doctors Think, suggests asking the following 3 questions:
1.What else could it be?
2.Is there anything that doesn’t fit?
3.Is It Possible I have more Than one problem?
Get a second opinion- Getting the opinion of two or more doctors reduces the chances of a wrong diagnosis. If the two diagnoses match, then the chances of a wrong diagnosis are much lower. And if they don’t match, then this is a puzzle that needs to be solved in order to get to the correct diagnosis. Many online second opinion services allow you to consult with world-renowned specialists from the comfort of your home. Lots of health insurers also offer their customers a free second opinion service, to help them make sure that their diagnosis is correct.
CrowdMed (www.crowdmed.com) uses the wisdom of the crowds to help solve diagnostic puzzles. It is an online medical crowdsourcing platform where you can submit information about your symptoms, medical history, tests, scan results and other pertinent data. This community of “medical detectives” then suggests diagnoses, and CrowdMed’s algorithms aggregate these medical differentials and distill them down to a probable list of diagnostic suggestions for you. This has an extremely high degree of accuracy, and is well worth exploring, especially when your doctor is stumped.
Step back and take a second look
Run different tests- If there are multiple diagnostic tests for your disease, consider having another type of test done.
Use a different laboratory- If you don’t trust your test results, you might want to get them repeated at a different laboratory.
Keep the originals- To reduce the risk of becoming a victim of diagnostic errors, always make sure you have originals of your tests. Make extra copies, preferably in digital format. These can be very helpful if you need to get a second opinion. You should also make sure that your doctor examines your original scans and X-rays, and not just the reports, because his interpretation may be different from the radiologist’s. If you have undergone a series of scans, they should be arranged in chronological order, so that the doctor can compare them easily.
Research your disease- The best way to feel confident about your diagnosis is to be well- informed and understand how it was made, Knowledge is power! You can use an online symptom-checker to help you make sense of what the diagnostic possibilities are. The trouble with many of these is that they may needlessly scare you; so you have to resist jumping to the conclusion that you have an incurable medical disease when you go online.
Patients are often the key to the right diagnosisEven though patients don’t have the medical tools and diagnostic skills that doctors do, they are the experts on their illness. An accurate medical history is the most valuable tool in helping the doctor to come to the right diagnosis, and often is far more valuable than expensive tests and esoteric scans.
It was Sir William Osler who said–“Listen to your patient, he is telling you the diagnosis.” Sadly, doctors are often too busy to take a proper history, and patients are often too disorganized, as a result of which they may fail to provide the doctor with valuable medical clues. Make detailed notes about when your symptoms started; what makes them better or worse; what treatments you’ve tried so far; and how they are related to taking medications, eating a meal, exercising, or a certain time of day.
By being clear, complete and accurate, and writing down your story in a structured format, it’s easier for the doctor to review your history, so he can make the right diagnosis!