Tuesday, October 14, 2014
Top 10 Reasons Doctors Screw Up Diagnoses
Part Two of a Six-Part series on Medical Care
Joe and Teresa Graedon, authors of Top Screwups Doctors Make and How to Avoid Them reflected on the simple fact that doctors are humans with limits:
Doctors have an impossible job. They have to learn way more information than any human is capable of retaining during their medical school education and residency training. Then they have to keep up with the latest developments in research and treatment despite grueling hours seeing patients. They frequently have to wrestle with insurance companies and all sorts of other bureaucratic bottlenecks. Finally, they are under enormous time pressure to see as many patients as possible. We have talked with many doctors who complain about having to practice “assembly line medicine.” It’s no wonder that sometimes doctors make mistakes.
Note: quoted passages are excerpts from Top Screwups Doctors Make and How to Avoid Them.
Because medical school and residency training promote the idea that doctors must come up with the correct diagnosis based on their own memories, physicians are destined to miss many diagnoses.
Lawrence Weed, MD, who has spent a lifetime studying these issues, has said:
The physicians’ unaided minds are incapable of recalling all the necessary knowledge from the literature and processing it with data from the unique patient. An epidemic of errors and waste is occurring as we persist in trying to do the impossible.
Dr. Weed and others who have recognized this problem suggest that physicians need to harness the power of information technology to avoid the high rate of missed or delayed diagnoses.
Mark Twain is reported to have said: “It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so.” Based on an analysis of available data, it is pretty clear that physician overconfidence is a major factor contributing to diagnostic disasters. . . . The problem with overconfidence is that doctors may not take the time or be willing to consider alternative possibilities for a patient’s symptoms. One reason for the epidemic of overconfidence is that doctors rarely get feedback about diagnostic screwups.
If you’ve ever had to clear away a stack of magazines you’ve been meaning to get to, but just couldn’t keep up with, you may have an inkling of what your doctor faces. There are thousands of medical journals spewing out the latest research in a never-ending tidal wave. A busy clinician who comes home exhausted cannot possibly read all the medical journals in her area of expertise. Throw in the Journal of the American Medical Association, the New England Journal of Medicine, and several other general medical publications , and there is just no way to keep up. Even if your doctor could read half of the relevant research in his field, remembering it, especially at just the right moment to help with a difficult diagnosis, is impossible.
Going it alone
Asking for help doesn’t come easily to many physicians. To get into medical school you have to be a superb student and very competitive. One doctor described such people as “top guns.” They are smart, bold, and driven. They are not necessarily people who instinctively know how to work well with others. Medical school and residency training don’t usually teach teamwork or ego-free collaborative problem solving. When faced with a diagnostic dilemma, such people are likely to try to solve the puzzle themselves. The trouble with this approach, however, is that if they get in over their heads, the patient may drown.
In How Doctors Think, Dr. Jerome Groopman talks about something called anchoring: “a shortcut in thinking where a person doesn’t consider multiple possibilities but quickly and firmly latches on to a single one, sure that he has thrown his anchor down just where he needs to be. You look at your map but your mind plays tricks on you — confirmation bias — because you see only the landmarks you expect to see and neglect those that should tell you that in fact you’re still at sea. Your skewed reading of the map ‘confirms’ your mistaken assumption that you have reached your destination.”
One of the reasons that so many doctors end up jumping to conclusions is a lack of time to stop and think clearly. They’re in a hurry all day long, dashing from one patient to the next. . . . Cutbacks in payments from insurance companies and the federal government have led many clinics and hospitals to encourage physicians to see more patients in less time. Some doctors have called this trend “hamster treadmill medicine ” or “assembly-line medicine.” Is it any wonder that physicians feel compelled to interrupt patients within twelve to twenty seconds after they start talking?
Missing test results
“Ordering and following up on outpatient laboratory and imaging tests consumes large amounts of physician time and is important in the diagnostic process. Diagnostic errors are the most frequent cause of malpractice claims in the United States; testing-related mistakes can lead to serious diagnostic errors. There are many steps in the testing process, which extends from ordering a test to providing appropriate follow-up; an error in any one of these steps can have lethal consequences.” Lawrence P. Casalino, M D, et al., in Archives of internal Medicine, June 22, 2009
Ignoring drug side effects
Just about every drug known to man has the potential to cause some side effects in some people. So how does a doctor who wants to do the best for his patient justify prescribing a medicine that could cause heart attacks, strokes, life-threatening liver failure, or kidney disease, to name just a few drug-induced side effects? . . . . When doctors fail to take patient accounts of side effects seriously, they are not likely to report the problems, either to the Food and Drug Administration or as a case report in the medical literature. As a result, other physicians also have more trouble making a connection.
One of the reasons that doctors sometimes don’t realize how frequently their diagnoses miss the mark is that they rarely get feedback on how the story ends. Under normal circumstances, the emergency department doctor won’t hear back from the physicians upstairs in the hospital . The specialist and the primary care physician may communicate, but perhaps not as much as one might hope. The patient with a puzzling constellation of symptoms may get passed from one doctor to another to a third or even a fourth before a diagnosis can be reached. At that point, the patient is generally so relieved to finally understand what is going on that she may not inform all the doctors she saw along this torturous path.
When patients go from one doctor to another, there is no organized system for hand-offs. This is often true even within the same hospital. Many diagnostic mistakes take place in the emergency department (ER). If you have ever had to go to the emergency room, you know what a bizarre setting it has become. There is almost always a waiting room full of people, and the wait time is interminable. Unless you are bleeding on the floor or having a heart attack or a stroke, you could easily be there for many hours before you are seen. The people who work in the ED are harried and often have to make snap decisions under pressure. In one study of malpractice claims, “approximately half of the missed diagnoses (52 percent ) involved emergency physicians.”
Whether during a hand-off or at some other time, communication failures cause problems. When patients don’t get to tell their whole story, important clues are missed. When doctors don’t communicate all relevant details to colleagues, the diagnosis and treatment can go horribly wrong. . . . Patients sometimes complain about having to repeat their whole history and all their symptoms to each health care provider they see, but instead of feeling miffed, they should take advantage of the opportunity.
As one can easily see, the fault can be shared by both the patient and the doctor. We must become a partner in our health care. Don’t assume that the doctor “knows best,” because only you know how you feel and are reacting to the medications you are prescribed.
Part Three will discuss Mistakes Doctors Make When Prescribing Medications.