Misdiagnosis: a medical menace to quality and safety of patient care

If patients weren’t already unhappy with drive-by medicine, in which clinicians spend on average of 15 minutes with them in an office visit, safety experts warn that too many doctors’  providing of harried care can worsen a medical menace that’s already hard to ignore: misdiagnosis.

Figuring out what ails a patient and taking a correct course of action already is a “complex, collaborative activity that involves clinical reasoning and information gathering,” reports Liz Seegert, a seasoned health journalist and a senior fellow at the Center for Health Policy and Media Engagement at George Washington University.

But, in a briefing posted online for her journalistic colleagues, she goes on to amass some eyebrow-raising information on diagnostic errors, their frequency, harms to patients, and why experts in the field see corrections in this area needed, stat. Among the data points she reports:

• Every nine minutes, someone in a U.S. hospital dies due to a medical diagnosis that was wrong or delayed.
• Roughly one in 10 patients with a serious disease is initially misdiagnosed
• Diagnostic errors affect an estimated 12 million Americans each year and likely cause more harm to patients than all other medical errors combined
• Misdiagnoses boost health costs through unnecessary tests, malpractice claims, and costs of treating patients who were sicker than diagnosed or didn’t have the diagnosed condition. Experts recently noted in a health care online report that inaccurate diagnoses waste upwards of $100 billion annually in the U.S.

Seegert gets these figures from the Society to Improve Diagnosis in Medicine, a group of doctors, researchers, health care providers, advocates and others that seeks to improve practices in the field to benefit patients and their safety. That group, headed now by a Johns Hopkins medical school professor, itself also points to works like the National Academies of Sciences, Engineering, and Medicine 2015 report Improving Diagnosis in Health Care.

Reporting from a recent, international conference targeting diagnostic errors and seeking to reduce them, Seegert finds experts focusing on causes and remedies, many pointing to one of doctors’ leading nightmares: their clocks. To maximize the profitability of practices, too many physicians see their schedules get packed too tight. They scurry from patient to patient, too often lacking the time to examine, document, and diagnose correctly.

Other factors may complicate matters further, as other recent reports suggest.

More and more complex diagnoses

Doctors, for example, may be escalating the number and complexity of their diagnoses, partly to comfort patients by offering them more certainty that the complaints they present with have a cause, argues Dhruv Khullar, a physician at New York-Presbyterian Hospital, an assistant professor in the departments of medicine and health care policy at Weill Cornell, and a contributor to the New York Times. He details this rising proliferation of diagnoses and its negatives, writing in a newspaper column on doctors:

Since the 1980s, there’s been rapid expansion in the number and complexity of medical diagnoses — a trend known as “medicalization.” A recent study found that the cost of 12 newly medicalized conditions — things like irritable bowel syndrome, post-traumatic stress disorder, low testosterone, attention deficit hyperactivity disorder — now approaches $80 billion a year, or about 4 percent of total health care spending. That’s about as much as we spend on heart disease or cancer, and more than we spend on public health initiatives. Our ever-expanding armamentarium of diagnoses no doubt offers comfort, attention and a path to treatment for many previously undiagnosed — and undiagnosable — patients. But we may also be medicalizing much of normal human behavior — labeling the healthy as diseased, and exposing them to undue risk of stigma, testing and treatment. Trouble sleeping is now insomnia. Shyness is social phobia. Grief is depression. Infidelity is sex addiction. It’s not that these diseases don’t exist — the spectrum of human behavior is broad, and the extremes do represent real pathology — but we may be drawing lines in the wrong places, with negative health and financial consequences.

As he points out, more and more complicated diagnoses lead to more screening and testing, drug prescribing, and administration of treatments. These aren’t cheap, and they send medical costs soaring.

The nightmare for MDs of electronic medical records

Meantime, Atul Gawande, a respected surgeon, writer, and public health researcher, in a new article in the New Yorker magazine, faults expensive, Rube Goldberg-like electronic health record (HER) systems for some of doctors’ harried state.

He says doctors are technically adept and tend to be computer friendly. But they’ve grown to hate EHRs viscerally, even though the systems costing tens of millions of dollars offer some conveniences that patients have come to like (such as easy appointment scheduling). For doctors, the systems have become a vast dumping ground, with too many caregivers allowed too much access, creating a daisy-chain, cut-and-paste information overload that forces doctors to turn away from patients, both to sort out the records’ mess before them, even as they contribute to it.

The consequences of doctors’ new preoccupation with laptops and their dearth of time and attention for patients can be seen in yet another new, published study in the medical journal Health Affairs. There, researchers found and analyzed patients’ own stories about their care, focusing on reports of so-called “adverse medical events,” situations involving errors serious enough to require their formal reporting in hospitals and other clinical settings.

Patients told how harried physicians engage in “unprofessional clinician behavior, including ignoring patients’ knowledge, disrespecting patients, failing to communicate, and manipulation or deception,” the Health Affairs researchers reported, adding that doctors and hospitals need to heed these complaints and respond to them to improve safe care.

Malpractice lawsuits as a response

If they fail to address misdiagnoses, Seegert cites a response that neither patients nor doctors favor but can be a last, powerful recourse: medical malpractice lawsuits. She points to a study by Johns Hopkins researchers, published in the medical journal BMJ, which scrutinized data from a quarter century of malpractice claims. The researchers, arguing for stepped up care and improvement in doctors’ diagnoses, concluded:

Among malpractice claims, diagnostic errors appear to be the most common, most costly and most dangerous of medical mistakes. We found roughly equal numbers of lethal and non-lethal errors in our analysis, suggesting that the public health burden of diagnostic errors could be twice that previously estimated. Healthcare stakeholders should consider diagnostic safety a critical health policy issue.

In my practice, I see not only the harms that patients suffer while seeking medical services but also the damages that can be inflicted on them by all too common misdiagnoses. They are a component of harmful and deadly medical errors. These kinds of mistakes claim the lives of roughly 685 Americans per day — more people than die of respiratory disease, accidents, stroke and Alzheimer’s. That estimate comes from a team of researchers led by a professor of surgery at Johns Hopkins. It means medical errors rank as the third leading cause of death in the U.S., behind only heart disease and cancer.

Doctors, medical practices, clinics, hospitals, and academic medical centers have the right to earn good and reasonable sums for solid care they provide. But they must be restrained from trying to maximize profits with excess patient volumes and high appointment churn, as well as by saddling highly trained clinicians with nonsense chores like typing in unnecessary detail in medical records or by forcing them to come up with fancy but unfounded diagnoses.

Doctors may need to holler first and loudest to stop this medical avarice. It overburdens them and their caregiving colleagues like nurses to the extreme, creating stress, family issues, and burn-out, as is documented well at the excellent site KevinMD, where practitioners write of their personal and professional trials and travails. Most doctors want to help patients, and they enjoy the personal contacts and close relationships that medicine is supposed to and must provide. If they can’t spend time with their patients, though, caregivers can become joyless drudges, slamming through a day like underpaid janitors in a warehouse. That’s not good for patients and the quality of their care or their safety. It’s past time to reconsider how to deal with misdiagnosis.