#dxaccuracy

  Eric Glazer   Vice President, Physician Engagement and Social Media   Best Doctors, Inc.

In Part 1, we looked at some of the barriers that physicians face related to diagnostic error. Now let’s explore a few solutions to help improve diagnosis.

 The reporting of diagnostic errors has always been inconsistent. Not surprisingly, in a profession that all but demands 100 percent accuracy, the culture can frown on physicians admitting any level of fault.

 When offered choices as to which action would most encourage the reporting of diagnostic errors, a majority (55 percent) of physicians felt confidentiality was an important enticement: Three out of ten (30 percent) physicians felt “incentives for hospitals from state and federal lawmakers to participate in confidential misdiagnosis data gathering and reporting” would be most helpful; 25 percent selected “confidential reporting/data-sharing on misdiagnosis as part of hospital accreditation.” 

Some physicians believe that “increasing the number of national events and conferences devoted to misdiagnosis” (17 percent) would most encourage reporting, while others saw a strong need for “a national voluntary misdiagnosis reporting system” (17 percent). Only 11 percent thought “a local champion that would encourage reporting” was the most beneficial action.

 Although encouraging physicians to report diagnostic errors is an important first step in elevating the issue, preventingerror is even more essential.

 When physicians were asked what they believe would be useful in improving diagnosis, the top three answers selected were “education about commonly misdiagnosed conditions”, “providing clear diagnostic algorithms for critical conditions” and “development of a secure online environment for collaboration with peers on challenging cases.”

These promising solutions to improve diagnosis will form the backdrop for the Diagnostic Error in Medicine 7th International Conference in Atlanta, September 14-17. Organized by the Society to Improve Diagnosis in Medicine (SIDM), the conference will bring together physicians, patients and public policy leaders to focus on topics including:

Reducing Diagnostic Error Through Improvement of Laboratory Test Utilization

Error, Overconfidence and Inadequate Feedback: Prospects for Systems Improvements

Clinical Decision Support — Bedside Tools for Better Diagnosis

Understanding and Misunderstanding Diagnostic Testing: A Source of Diagnostic Error

Placing Diagnosis Errors on the Policy Agenda

  Eric Glazer   Vice President, Physician Engagement and Social Media   Best Doctors, Inc.

In the March 2009 Journal of the American Medical Association, David Newman-Toker, MD, Ph.D., and Peter J. Pronovost, MD, Ph.D., of Johns Hopkins University, cited an estimated 40,000 – 80,000 US hospital deaths result per year from misdiagnosis. To help put an end to this preventable harm, Best Doctors surveyed more than 1,300 physicians in specialties ranging from allergy and immunology to vascular surgery to get their perspective on this problem and how to solve it.

In general, the study found that doctors are very concerned with misdiagnosis (a diagnosis that is wrong, missed, or could have been made much earlier): over 7 out of 10 doctors (71 percent) view the problem as “extremely important” or “important” compared to other adverse patient outcomes. Only 3 percent of physicians reported that a misdiagnosis was “not at all a problem.”

However, many physicians don’t see diagnostic error as an issue in their practice but rather a problem in other doctors’ offices. In fact, 20 percent cite a misdiagnosis in their practice “almost never” occurs while 39 percent estimate it happens “once a year.” Still, some physicians (34 percent) say a diagnostic error occurs in their practice “about once a month.” It’s often difficult to pinpoint the reasons behind a misdiagnosis. It’s certainly not about a physician’s ability, nor does it mean a doctor doesn’t care. Rather, there are a variety of factors that can contribute to a misdiagnosis. When physicians were asked to choose the most significant barrier to improve diagnostic accuracy, the results confirmed problems that have existed for too long in the health care industry. The top reason chosen by 35 percent of physicians was “fragmented or missing information across medical information systems” followed by “inadequate time for patient evaluation” (30 percent) and “incomplete or inaccurate medical history provided by the patient” (19 percent).

Check back here Thursday for part two and see what physicians feel are the most useful ways to help improve diagnoses.

        Leana Wen, MD   Emergency Medicine    George Washington University   @DrLeanaWen | www.drleanawen.com

From an early age, I knew I wanted to be a doctor. In medical school, my mother was misdiagnosed for a year before she was finally diagnosed with metastatic cancer. Through this experience I learned how important it is to learn to be your own best advocate. Getting to the right diagnosis is so important because if the diagnosis is wrong, then so is everything else that follows. The story and history behind one’s illness is critical to getting to the right diagnosis. Best Doctors and I have synergistic messages, stressing the importance of a second opinion and speaking up when something isn’t right.  

For more Best Doctors videos, click here. 

  Mark Lewis, MD   Assistant Professor in General & GI Oncology, MD Anderson Cancer Center   marklewismd

"Are we still friends?" 

It's the half-joking question I pose as I walk into the exam room of the patient to whom I have just administered chemotherapy. The first treatment is always instructive and clarifying for both of us, preceded by the hazy prophesying of informed consent. I like to mock the television commercials for prescription drugs, so artfully composed by the pharmaceutical companies, who run a breathless audio description of their product's most fearsome side effects with deliberate incongruity beneath video of smiling attractive couples on adventurous vacations. But if I'm honest, I'm guilty of the same salesmanship, rushing through the litany of potential outcomes (and similarly likely to mention death as fleetingly as possible) before advising my patients to sign on the dotted line with the assurance that, in my professional medical opinion, the benefits likely outweigh the risks. For all the talk of darkness, the future looks bright. 

How differently things can seem at our next encounter, ideally meeting again during a scheduled office visit but sometimes in the ER, on the hospital ward, or in the ICU. That laundry list of possibilities with which I deluged them at our prior appointment has now been narrowed, distilled into a present reality that might include intractable nausea, cholera-like diarrhea, or febrile neutropenia. Clouds have intruded on a sunny forecast, and it's time for the weatherman to accept blame. 

I do my best to survey the damage, even quantify it (although I have yet to meet a patient who describes their disabling paresthesias as grade 3 neuropathy); make adjustments (I have great empathy for the coach whose team is losing badly at half-time); and then move on, mingling my regret with the sincere hope that things will be better the next time, learning from the past lest we be doomed to repeat it.

So when I ask the patient if we're still friends, it's a feint towards an admission of guilt. I recognize this is the life cycle of an abusive relationship: I inflict harm, I ask for forgiveness, I try to re-establish trust, and then I do it all over again. We even number the chemo treatments in cycles, reminding ourselves of time's flat circle, the not-so-merry-go-round. Along another axis, it can be seen as a roller coaster: a plunge into toxicity, an ascent back to baseline, and then another precipitous decline. 

The ethics lessons from first-year medical school resound accusingly in my head: primum non nocere --  First, do no harm. As a student this seemed a self-evident, easy morality (and boy, don't I sound sophisticated saying it in Latin?!). But it turns out to be a precept that's extremely hard, if not impossible, for a medical oncologist to follow. I am a blunt instrument, and I cause collateral damage despite my best intentions to take careful aim at an often-elusive target inside another person. 

   Jennifer Derebery, MD    Associate at House Ear Clinic, Inc    Clinical Professor, Department of Otolaryngology at the University of Southern          California School of Medicine 

Though dizziness symptoms are common, I consider diagnosing the cause challenging due to the complexity of their possible origins. When diagnosing dizziness, I like to use the “three-legged stool” approach that places the brain as the master center of balance or the seat of the stool; with the three legs supporting the seat refer to the dizziness’ origin. The three legs are as labeled:

Vestibular System – The sensory mechanism in the inner ear that detects movement of the head and helps to control balance

Proprioceptive System – The sensory receptors that are found in the skin, muscles and joints that are sensitive to stretch or pressure in the surrounding tissues

Visual System – The sensory receptors in the retina when affected send impulses to the brain that provide visual cues identifying how a person is relative to the other objects they are looking at

Using the “Three-Legged Stool” approach to pinpoint the high level sources of the dizziness, you can begin to refine your original diagnosis. I also, outlined three types of differential diagnosis:

Peripheral – Inner Ear

Central – The Brain

Systemic – Leading to a symptom                             

After going through the basics, make sure to incorporate the patient in the diagnosis.  It is essential to make the patient feel like they are contributing to their own diagnosis, so make it a point to ask the patient two important questions when diagnosing dizziness: 

What the patient means by dizziness

Does the patient feel they are “spinning,” as with vertigo?

Do they feel “drunk” or imbalanced?

Timing of dizziness-  Depending on the time frame, diagnosing the cause of dizziness can vary

Seconds of dizzy sensations could indicate benign positional vertigo

Minutes of dizziness could indicate a circulatory problem

Hours of dizziness could indicate Meniere’s or migraine

Days of dizziness could indicate viral labyrinthitis, and probably excludes the possibility of an inner ear problem

Constant dizziness probably does not indicate a primarily otolaryngological disorder

Whether the patient is experiencing  hearing loss problems in one half of the inner ear can often affect the other

The pattern of the hearing loss can also offer clues to inner ear problems

Presence of hearing loss symptoms, plus the timing of the dizziness, are two strong indicators in the source of dizziness

The severity of the diagnosis can be quickly made through a proper imaging study and physical examination. Determining whether it is a hemorrhage or a central nervous system problem can be accomplished with a simple exam or imaging study.

Recurring symptoms of benign positional vertigo can often indicate migraine. Keys indications are headaches or other forms of head discomfort, but also can include motion-induced dizziness such as spinning or imbalanced sensations, even if they haven’t experienced these symptoms in several years. Ask the patient whether they are bothered by light or loud sound: these symptoms would also indicate possible migraine. For treatment options, watch Diagnosing Dizziness: Tips for the Primary Care Doctor.

  Arshya Vahabzadeh, MD   Leadership Fellow, American Psychiatric Association   Laughlin Fellow, American College of Psychiatrists   Physician in Child and Adolescent Psychiatry, Harvard  Medical School   Mass.General Hospital / McLean Hospital   VahabzadehMD.com | @VahabzadehMD

If you found that question a little tricky then you are in the majority of physicians. I can, however, tell you what diagnostic overshadowing is not: it is not something found on poorly radiographed x-ray film, or a situation that arises when a medical student obstructs an operating room light. It is much more serious, and all too often contributes to a lack of prompt medical diagnosis and treatment.

Diagnostic overshadowing refers to the process of over-attributing a patient’s symptoms to a particular condition, resulting in key comorbid conditions being undiagnosed and untreated. Diagnostic overshadowing was originally described in people with developmental disabilities, where their psychiatric symptoms and behaviors were falsely attributed to their disability, leaving any comorbid psychiatric illness undiagnosed. Increasingly, research has also shown that comorbid medical conditions are often “diagnostically overshadowed” by the presence of a prior psychiatric disorder or developmental disability diagnosis.

It is believed that diagnostic overshadowing contributes to the excess medical morbidity and mortality seen in individuals with psychiatric or developmental disorders.  These findings are of considerable concern given that 1 in 4 adults in any year, and 1 in 5 children in their lifetime will be diagnosed with a mental health disorder. Regardless of the field of medicine, or the setting of care, physicians will routinely encounter people with these disorders.

There are a range of practical steps that we can take to minimize diagnostic overshadowing. Some of these steps are relatively easy to undertake, others require a greater initial investment of time but can lead to better and more timely medical diagnosis and treatment.

5 Strategies to help minimize diagnostic overshadowing

  1. Objectively assess your diagnostic and treatment planning.

Consider the question “Are you doing the same investigations that you would do in someone who did not have a psychiatric or developmental disorder?” Try to be objective in this regard, routine medical care is often lacking in people with severe psychiatric and developmental disorders.

  2. Liaise with their psychiatrist or other behavioral specialist.

Patients who have psychiatric disorders or developmental disabilities often benefit from having access to a psychiatrist or other behavioral specialist. With appropriate patient consent, it is often useful to communicate with the psychiatrist, especially in developing treatment plans and follow-up. On occasion, a patient may not have access to such a specialist, in which case it would be prudent to recommend a psychiatric consultation.

  3. Obtain collateral history from their families and caregivers.

Many patients with severe psychiatric disorders or developmental disabilities often rely on family members or other caregivers for help and support. With appropriate consent, collateral information from these individuals can be invaluable. In patients who have difficulty in communicating, changes in behavior from baseline are very important to detect. Abrupt changes in behavior or sudden onset of symptoms should warrant medical causes to be ruled out.

  4. Being aware of our own attitudes and that of our colleagues.

Clinicians’ attitudes have long been highlighted as a prominent cause of diagnostic overshadowing. There is considerable stigma associated with psychiatric disorders and developmental disabilities, even among healthcare professionals. Studies have highlighted that healthcare professionals may hold more negative views regarding the treatment and prognosis of patients with mental health disorders or developmental disabilities. It is up to us to define what our workplace environment will be like; we must be able to be aware of our own blind spots and set an example for our colleagues, allied healthcare professionals, and medical students.

  5. Learning more about mental health and developmental disabilities.

Learning more about conditions such as autism, bipolar disorder, or schizophrenia can help physicians to have a clearer picture of symptoms that are inconsistent with the mental health or developmental diagnosis. It would be unusual to have a patient with autism who appears to be hallucinating or complains of headaches, as these are not routinely encountered symptoms and warrant further investigation.