Most of the attention given to medical errors concerns institutional issues, such as surgical mistakes, hospital medication mishaps, lack of infection control and emergency room misdiagnoses, or individual caregivers who are woefully deficient in the practice of medicine. But a new study in JAMA Internal Medicine makes clear that primary care patients also are routinely at risk of misdiagnosis.
As reported on Reuters.com, the research shows that when it comes to analyzing and resolving medical errors, relatively little attention has been paid to what happens in your primary care doctor’s office.
And that oversight is itself a mistake.
The JAMA researchers analyzed electronic health records to track 190 diagnostic errors made during primary care visits at two health-care facilities. The misdiagnosed patients in all of those cases were hospitalized or came back to the doctor’s office or emergency room within two weeks.
There was a variety of mistakes, but pneumonia, heart failure, kidney failure and cancer each accounted for 5 to 7 out of 100 problems doctors first diagnosed as something else.
Although some of the mistakes were relatively harmless, some were lethal. Of the 190 cases, 36 patients had serious, permanent damage, and 27 died.
Dr. David Newman-Toker of Johns Hopkins University School of Medicine told Reuters “You’re really talking about at least 150,000 people per year, deaths or disabilities that are resulting from this problem.”
Diagnostic challenge is part and parcel of the practice medicine, which depends on both science and art. A patient who shows up in the doctor’s office with mild shortness of breath and a routine cough with a little phlegm might lead a doctor to diagnose bronchitis. But, as one of the study authors told Reuters, “… lo and behold they would come back two days later with heart failure.”
The art of diagnosis will always have its hits and misses, so what can practitioners and patients do to maximize the former and minimize the latter? As we’ve said before, a lot of errors-and their harms-can be avoided if doctors practice the basics and if the doctor-patient relationship is based on mutual respect and communication.
Most of the missed diagnoses, the study showed, were because the doctor failed to get an accurate patient history, do a full exam or order the correct tests. Patients periodically should review their files to ensure they contain a full medical history. They should ask certain questions about the purpose of each exam and test-for a list, see our blog “Inquiring Minds Want to Know: Questions Patients Should Always Ask.”
The researchers suggested that minimizing errors in primary care situations might require changes in doctor training to prepare them for patients who come to their appointments armed with all of the relevant information about the nature and timing of their symptoms.
“I do think it’s important for a patient to question or observe the doctor,” Newman-Toker told Reuters. “Ask pointed questions: ‘What else could this be? What things are you most concerned about?'”
And patients, he said, should “not just assume that once the diagnosis has happened the first time, that everything is said and done and that it’s all over. You just can’t have blind obedience to the doctor’s diagnosis.”
So if you develop new symptoms or your symptoms get worse after you see the doctor, don’t assume everything is fine because the initial diagnosis was not something serious. Your job as a patient is to understand that making a diagnosis involves uncertainty, because symptoms and circumstances can change, and to follow up if they do.
As one of the study authors said, “We need to get patients more engaged in the conversation with the providers. [T] he main message is: How do we effectively (make diagnoses) together?”