MD True Confessions: Doctors Admit Their Diagnostic Errors
Medical Confessional Uncovers Most Common Mistakes Doctors Make
Gordon D. Schiff, MD
Harvard Medical School
Harvard Medical School
Special from Bottom Line's Daily Health News
June 17, 2010
June 17, 2010
T o my mind, this was an amazing research project... more than 300 doctors were encouraged to anonymously confess diagnostic errors that they had made or witnessed. The goal was to identify the most common types of diagnostic mistakes doctors make so as to develop safeguards to minimize or prevent them from happening in the future. This is a terrific opportunity for us to learn where our doctors are most likely to go wrong so that we consumers can do our best to keep our medical care on the right track and avoid dangerous misdiagnoses.
Why So Many Mistakes?
Just over 10 years ago, a landmark study by the Institute of Medicine indicated that up to 98,000 Americans die each year as a result of medical errors. Since that time, medical professionals have taken steps to streamline and improve patient safety, yet this new study shows that doctors are still dropping too many balls, observes study coauthor Gordon D. Schiff, MD, an expert in patient safety at Harvard Medical School.
Dr. Schiff and his team distributed a written survey to 310 doctors at 22 institutions across the US asking them to share three cases of diagnostic error -- defined as any mistake or failure in the diagnostic process that led to a misdiagnosis, missed diagnosis or delayed diagnosis. They learned lots about particular types of errors...
- Major, minor and somewhere in the middle: Doctors reported 583 errors. Of these, 180 (31%) were self-rated as minor, 241 (41%) as moderate and 162 (28%) as major.
- Most likely to be misdiagnosed: Pulmonary embolism (26 cases, 4.5%) was the condition most likely to be misdiagnosed, followed by adverse drug reactions or overdose (26 cases, 4.5%)... lung cancer (23 cases, 3.9%)... colorectal cancer (19 cases, 3.3%)... acute coronary syndrome and/or heart attack (18 cases, 3.1%)... breast cancer (18 cases, 3.1%)... and stroke (15 cases, 2.6%).
- Not asking... and not telling either: Doctors most often made errors related to ordering or following up on lab or radiology tests (44%). Other common errors included over- or under-consideration of competing diagnoses (32%), problems with history taking (10%) or physical examination (10%), and referral or consultation errors or delays (3%).
These results were published in the November 9, 2009, issue of Archives of Internal Medicine.
What Can You Do?
The results highlight the need for ultra-reliable mechanisms to catch those "dropped balls" in order to be sure that patients promptly and accurately receive test results and other important information, says Dr. Schiff. He offered an example of one such fail-proof strategy: At his hospital, Brigham and Women’s in Boston, a new system ensures that physicians receive and acknowledge lab and radiology results, which are also automatically communicated (by letter or confidential e-mail) to the patient. He suggests that yet another layer of improvement might be to have automated follow-up calls to see whether patients are improving as expected -- and if not, start a process to evaluate whether the initial diagnosis may have been incorrect.
But it’s not smart to wait for the medical community to solve this problem -- we patients, too, need to take action to protect ourselves from these types of errors. It’s the only way to ensure that we’re getting optimal medical care.
Dr. Schiff shared some suggestions...
- Be aware that certain types of diagnoses are harder to make than others. The top error categories (pulmonary embolism, stroke and heart disease, along with colorectal, lung and breast cancer) are often challenging -- not all patients have the same symptoms, and the typical symptoms don’t always indicate the presence of a serious medical condition. If you don’t improve or if you develop unexpected new symptoms, absolutely question your doctor about your diagnosis -- perhaps it is incorrect.
- If you are worried or in pain, bring someone with you to your medical appointment or the emergency room. It’s hard to think clearly under these circumstances. It’s helpful to have another listener -- and an advocate to speak on your behalf if a health-care provider seems dismissive, distracted or is otherwise not providing the care and feedback you need.
- Be proactive in communicating with your primary care physician. You know your doctor has lots of patients and relatively little time, so arrive at each appointment with a written list of your key questions -- it’s a good idea to jot down the answers, too.
- Promptly report any new symptoms, and keep written records of all medications, treatments and tests. Especially if you are referred to a specialist, this can help prevent inconvenient, costly and potentially dangerous drug interactions or procedure duplications.
- Don’t agree to have tests you don’t need, which could lead to more opportunities for wrong diagnoses. Research increasingly suggests that computerized tomography (CT) scans and other tests are overused, exposing patients to unnecessary risks and sometimes leading to false positives (or false negatives if the CT isn’t the best test for a particular condition)... further unnecessary testing... and even unnecessary treatment. Before you have any imaging test, make sure you understand why it is necessary. Discuss other possible options, and -- as above -- keep records to avoid duplicate testing.
- Always follow up with your doctor. Never assume that no news is good news, Dr. Schiff emphasizes. If you have a test and the office doesn’t inform you about results within the expected time frame, call. (Note: See our report on the consequences of this particular medical error in Daily Health News, May 6, 2010.)
- Practice full disclosure. Be honest and upfront. Do not hide anything from your doctor. Be open about even potentially embarrassing habits, such as smoking, alcohol or drug use or unsafe sex, says Dr. Schiff, so doctors have all the information and clues needed to make the right diagnosis. Withholding information can lead your doctor astray in diagnosing your problem.
- It’s better to share too much information than too little. The more information your doctor has, the more accurately he/she can assess your well-being. For instance, a recent trip abroad may explain your upset stomach symptoms. A new medicine might account for sudden problems such as dizziness or disorientation. If a close family member had cancer and you’re worried that you have it, too, share this concern.
- Get second opinions. When you are uneasy about making a major medical decision, it’s wise to seek several opinions. You may feel awkward, but a confident and experienced doctor is not threatened by a second opinion, and getting one may increase your chances of better care. (See Daily Health News, "It’s Good to Second Guess Your Doctor," 8/21/07.)
And, finally, don’t hesitate to stand up for yourself. You should never feel afraid to approach a physician if you don’t agree with his/her advice -- you can do this respectfully while also making sure that your concerns are addressed, Dr. Schiff said. And if you can’t -- it might be time to diagnose yourself as being in acute need of a different doctor.
Gordon D. Schiff, MD, associate professor of medicine, Harvard Medical School, clinician researcher in the area of patient safety and medical informatics, Brigham and Women’s Hospital, Boston.
