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“There is a crack, a crack in everything … That’s how the light gets in.”
Leonard Cohen
DIAGNOSIS is one of the most complex and challenging tasks facing physicians. Despite our best intentions and efforts, the rate of diagnostic error in medicine is in the range of 10–15%.
Patient safety efforts in medicine have focused to date on systems improvements, such as improving rates of hand hygiene and preventing medication and procedural errors. Diagnostic errors have represented something of a “blind spot” in patient safety endeavours because they are difficult to define, measure and study.
In 2015, the Institute of Medicine published the report Improving diagnosis in health care as part of the Quality Chasm series. As a result of this landmark report, diagnostic errors will finally be given the attention and respect they deserve. Reducing diagnostic error in medicine and striving for diagnostic excellence is the next frontier in patient safety.
The report highlights that improving the diagnostic process is not only possible, it is a moral, professional and public health imperative.
Why do diagnostic errors occur with such frequency? According to the Institute of Medicine report, often it is because of inadequate collaboration and communication among clinicians, patients and their families, non-supportive work systems and a failure to receive feedback.
The challenge that is diagnosis
Patients come to see us hoping for an accurate and timely diagnosis, but diagnosis is complex, an inexact science, fraught with paradox and contradictions. A seemingly benign symptom may herald a serious diagnosis, while a dramatic presentation may be symptomatic of a self-limiting and less serious disease process. Diagnosis evolves and our initial diagnosis, or in some cases multiple diagnoses, often require revision with the passage of time.
What is more, we do not always have optimal conditions for diagnosis. In fact, it is rare for us to do so. We are often rushed, stressed, multitasking, interrupted and wrestling with an electronic medical record or technology. The tests we order have limitations; there are false positives and negatives, as well as confounding incidental findings. Our patient test results come back when the patient is no longer in front of us. Some of the results we cannot understand. Our colleagues (radiologists, pathologists and subspecialty doctors) may be difficult to contact. They say the same about us. We are often living and working in diagnostic silos, unable to connect with each other, despite advances in technology.
Sometimes we may wonder whether we are good diagnosticians at all. It can be difficult to get feedback on the diagnoses we make. Certainly, most of us do not get systematic feedback on our diagnoses. If we misdiagnose a patient, it is likely they will go to another doctor. Our colleagues too may be embarrassed to tell us if they see a patient that we have misdiagnosed. Fear of making a diagnostic error is a potent contributor to stress and burnout.
How are we to learn from our errors and improve diagnostic performance?
A new paradigm in diagnosis
The medical educator Robert Trowbridge writes that we need to “encourage learners to embrace the uncertainty of clinical medicine and to enjoy rather than dread the diagnostic process”.
We should no longer consider the diagnostic process as something that occurs in the head of a single physician, the responsibility for which lies with them alone.
Diagnosis is coming to involve a team of clinicians with work systems designed to support the diagnostic process and facilitate communication between team members. Error recovery mechanisms should be integrated into these work systems. We need to make getting feedback on our diagnoses the norm, not the exception. In medical education, the role of diagnostic competencies should be explored.
Diagnosis is about teamwork, relationships and communication, about opening up to each other and sharing. The patient shares their symptoms and allows us to examine carefully for clinical signs that may support or refute a diagnosis. In turn, we share our thought processes, diagnostic hypotheses and even our differential diagnoses with our patient.
We share our patient with other clinicians, with nurses, ultrasonographers, radiologists and pathologists, who help us in the quest for a diagnosis. When we enter the diagnostic relationship with our patient, we have to weather the diagnostic uncertainty, as we proceed with our joint investigation into what’s going on. The diagnostic process can be an emotional rollercoaster for clinician and patient alike. Together we seek clarity, we keep an open mind, we are enquiring and open to unexpected possibilities.
All clinicians will be involved in diagnostic error in their careers. Sometimes, when the storm of a misdiagnosis passes, we look back, we share our story with a colleague or a medical student. We may reflect on our thought processes, our cognitive biases, our emotional state, perhaps on patient characteristics. We may marvel on the vagaries of disease presentation.
However, we want our experience not just to be etched in our memory and that of our patient, but to contribute to preventing a future diagnostic error.
From 23–25 May 2017, the first Australasian Diagnostic Error in Medicine Conference will be held in Melbourne, run by the Society to Improve Diagnosis in Medicine.
It will bring together local and international leaders in the field of diagnostic safety. This interdisciplinary event will be no ordinary medical conference. The art and science of diagnosis will be unravelled and examined. Alongside keynote presentations, actors will explore, in workshops, the varied roles we play in the diagnostic process, how our emotions may influence clinical reasoning, how our reactions to patients may affect us “getting it right”.
The language of diagnosis will be explored, as well as ways to regain trust and apologise after a diagnostic error. The art of listening will be analysed. Patients who have been misdiagnosed will share their views on how we can work together to improve diagnosis. The role of nurses in diagnosis will be acknowledged and examined. Radiologists, pathologists, generalists and specialists will share insights into diagnostic errors in their fields and how they can be reduced.
See you there!
Dr Carmel Crock is director of the emergency department at the Royal Victorian Eye and Ear Hospital. She chairs the Australasian College of Emergency Medicine’s Quality subcommittee, is a fellow of the Melbourne Medical School Academy of Clinical Teachers and a founding member of the Society to Improve Diagnosis in Medicine in the USA. She studied the violoncello in France and Italian literature in Italy, and has a Bachelor of Letters in Italian language and linguistics from Monash University. Her passions in medicine include preventing diagnostic error, improving health care culture and the relationship between physician wellbeing and patient safety.
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Thanks very much for your comment, Sue. Gordon Schiff talks about “conservative diagnosis”, which I think is what you are referring to, too.
Thanks for an important article, Carmel. The uncertainty and shame that comes from “misdiagnosis” is part of the harms of a risk-averse society that uses over-testing and over-diagnosis as a false reassurance against inevitable uncertainty. We need to re-claim the important tools of time, observation and review, and recognise that not every self-limiting symptom needs a diagnosis. Indeed, the quest for diagnosis can lead to harm. Rather than look for fault in each other, we need to look at what practice best benefits the patient.
Our dumbed-down institutional “risk-management” (risk avoidance) systems need to be redesigned to recognise that uncertainty is inevitable, and that attempts to reduce risk below certain levels create additional risks and harms in their own right.