Mistakes even good doctors make

Mistakes even good doctors make

Getting the right diagnosis isn’t easy, especially when doctors are rushed

Published: October 2013

Get the first appointment of the day.
That way your doctor is less likely to rush you because he or she is running late.

When something is wrong with us, we go to a doctor with the expectation that he or she will figure out what the problem is and what to do about it. But despite all the advancements in modern medicine, doctors make the wrong diagnosis in 10 percent to 15 percent of office visits for a new problem, studies suggest.

Lest you think that those misdiagnoses involve seldom-seen conditions, a March 2013 study of 68 such cases in primary-care settings (a large urban Veterans Affairs facility and community-based clinics) found that the most common ones include urinary-tract infections, pneumonia, congestive heart failure, acute renal failure, and cancer.

Those are “common diseases that are the bread and butter of primary care,” said Hardeep Singh, M.D., M.P.H., the study’s lead author and a patient-safety researcher at the Houston Veterans Affairs Center for Innovations in Quality, Effectiveness, and Safety. Even if the doctor’s mistake is corrected later, the misdiagnosis can drive up medical costs if it leads to unnecessary appointments or tests.

Misdiagnoses occur twice as often in doctors’ offices than in hospitals. But when the error happens in a hospital, it can have more dire consequences, largely because the patients there are a little sicker to begin with, says David E. Newman-Toker, M.D., Ph.D., an associate professor of neurology at the Johns Hopkins University School of Medicine in Baltimore.

As many as 160,000 hospitalized patients die or suffer a significant, permanent injury each year because health care providers either misdiagnose a condition, arrive late at a diagnosis, or miss the problem completely, according to a report by Newman-Toker and colleagues in the August 2013 issue of BMJ Quality and Safety in Health Care.

Why do doctors make mistakes, anyway?

Errors occur, but it’s not necessarily because doctors aren’t smart or caring. Coming up with a medical diagnosis can be one of the most difficult tasks physicians perform, for a few reasons. They have to figure out what’s wrong with you when there’s limited time (an average office visit lasts only about 21 minutes). And the information you provide might be incomplete because you’re not providing an accurate history or you’re not able to articulate your symptoms.

Visits with even the most diagnostically astute physician can go awry if he or she is interrupted multiple times by staff members while talking to you, or the doctor is rushed due to an unusually large caseload. And the office staff might inadvertently send a doctor down the wrong path by entering the wrong chief complaint in the electronic health record.

Sometimes it’s not the doctor’s office that makes an error but the people who do the testing. Laboratory results are wrong or misleading in 2 percent to 4 percent of cases, according to a review published online in BMJ Quality and Safety on Aug. 7, 2013. About the same error rates were found in diagnostic radiology test results.

Patients can contribute to the mistake-making process by missing follow-up appointments or failing to get requested tests or imaging. Withholding vital medical information—for example, that they’ve stopped taking their pills—can also throw doctors off-track.

Then there’s the simple fact that doctors, no matter how brilliant, sometimes fall into certain “cognitive traps,” says Jerome Groopman, M.D., chief of the division of experimental medicine at Beth Israel Deaconess Medical Center, and author of “How Doctors Think” (Houghton Mifflin, 2007). Groopman describes three pitfalls that can lead to diagnostic errors:

  • Anchoring a diagnosis to the first bit of information provided by the patient and following what Groopman calls a narrow path of thinking; for example, focusing on symptoms that suggest acid reflux and not considering that they could also stem from a serious heart problem.
  • Connecting symptoms to similar complaints experienced by other patients who had less-serious problems.
  • Letting stereotypes interfere with clinical judgment; for example, assuming that a patient with a disheveled appearance could have a drinking problem.

By understanding these traps and being on the lookout for them, Groopman says, patients can work with their doctors to help arrive at the correct diagnosis.

How to get the right diagnosis

In Singh’s study, almost 80 percent of the misdiagnoses could be traced to a breakdown in communication between doctor and patient. They included missteps in taking a patient’s medical history (especially when the patient failed to provide information or had difficulty communicating it and family members couldn’t assist), errors doing physical exams, and misinterpreting diagnostic tests. That underscores the importance of being involved in the process of diagnosing your condition, starting with when you make that first appointment. These steps can help.

Make your appointment early

Try to schedule it earlier in the day so that your appointment is less likely to be shortened because your doctor is overbooked and is running late. And if you think you’ll need more time than usual or are going in to discuss a brand-new problem, say so when scheduling.

Come prepared

Put a list of your health complaints together ahead of time, and prioritize them because time might be limited. Also make note of the chronological order of symptoms related to each complaint. And bring a detailed medical history with a list of all the medications, including dietary supplements, you are taking. (It’s a good idea to keep a copy of that list in your wallet for medical personnel to access in the event you’re ever unconscious. You should also keep contact information in your cell phone under the listing “ICE”—“in case of emergency”—for the same reason.)

Bring a buddy if possible

Whether going to your doctor’s office or to a hospital, ask a companion along to be your advocate, help you remember what transpires, and get your doctor’s full attention. If you can’t bring someone, take notes so you have a record of what went on.

Ask targeted questions

Help ensure that your doctor is thinking about your problem and giving it serious attention by asking key questions that encourage broad thinking. For example, if you come in complaining of fatigue and weight loss and the doctor says it sounds like a thyroid problem, say, “Is there anything else it might be?” If the answer is no, then say, “Why do you think that?” Expect well-reasoned answers. He should be able to explain, for example, how your symptoms align with the condition he’s considering.

Insist on a diagnosis

Singh’s study found that primary-care providers failed to document a differential diagnosis—a list of diagnoses it could be—in 81 percent of the initial visits from their patients. If you go in with serious symptoms, such as shortness of breath, don’t hesitate to ask the doctor what might be causing them and how she plans to go about making a diagnosis, such as further tests or a referral to a specialist. Make sure you understand what the next steps are before leaving the office.

Take charge of your test results

If you’re sent for more tests, particularly those related to heart disease or cancer, ask when you should expect the results. If you don’t receive them within that time frame, contact your doctor. “No news is not necessarily good news,” said Marvin M. Lipman, M.D., Consumer Reports’ chief medical adviser. You should read the details of all imaging and lab reports and ask your doctor for help interpreting them. Also ask how any abnormal results should be followed up, such as additional testing or even seeking a second opinion.

Staying on top of the process can save critical time. In a recent study of 587 patients with lung cancer at Veterans Affairs medical centers, for example, clinicians who failed to send patients for follow-up tests after abnormal test results and patients who didn’t get those tests in a timely fashion led to delayed diagnoses in more than one-third of the cases.

Monitor your progress

If your doctor says that you should feel better under his treatment plan and you don’t, or you’re feeling worse or experiencing different symptoms, let him know. In Singh’s study, most of the harmful diagnostic errors were detected because patients were unexpectedly hospitalized or made a return visit to the doctor when their symptoms didn’t improve. He also found that mistakes from notes in patient’s files often contributed to errors. So ask to see your medical record to check on the accuracy and completeness of your doctor’s notes as well as your medical history and medication list. Compare them with your own notes and point out any errors.

Get another opinion if needed

If you lack faith in your physician or your condition isn’t resolved within a reasonable time period, it makes sense to get another provider thinking about your case. Doctors are legally bound to cooperate with patients seeking a second opinion, including sending records, prescriptions, test results, letters, and photographs to other physicians. If your doctor discourages you from seeking another opinion, consider it even more reason to get one.  

The 5 problems doctors miss the most

These five conditions were the most likely to be overlooked, diagnosed late, or mistaken for something else in primary-care settings.


• Cancer (metastatic or leukemia, lung, or pancreatic)


• Pneumonia


• Congestive heart failure


• Kidney failure


• Urinary-tract infection


Source: “Types and Origins of Diagnostic Errors in Primary Care Settings,” JAMA Internal Medicine, March 25, 2013.


 


 


Editor's Note:

This article appeared in the November 2013 issue of Consumer Reports on Health.



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