Vital Signs Blog

Blog: 'Difficult' patients more likely to be misdiagnosed

Patients who frequently demand tests and procedures, have low expectations of their doctors or tend to ignore clinical recommendations are more likely to be misdiagnosed.

Medical residents dealing with “difficult” patients were 42% more likely to get the diagnosis of a complex medical case wrong and 6% more likely to get it wrong on simpler cases, found a study published in the BMJ Quality & Safety, a journal of the British Medical Association.

Doctors tend to think they are immune from the “emotional pull” of clinical encounters, and often deny their judgment is influenced, noted researchers from the Institute for Medical Education Research in the Netherlands. “The fact is that difficult patients trigger reactions that may intrude with reasoning, adversely affect judgment and cause error.”

The study is one of two published Monday by the journal that explore factors leading to diagnostic errors, a problem more frequently catching the eye of healthcare safety leaders.

It is estimated that about 5% of outpatients experience a diagnostic mistake each year, and that 1 out of 10 patient deaths may be related to these oversights, according to the National Academies of Sciences, Engineering and Medicine. The problem, a “blind spot” prevalent throughout all healthcare settings, is one that can't simply be blamed on bad doctors, according to a long-awaited report the group released in September.

The 1999 landmark To Err Is Human report placed national focus on problems such as wrong site-surgeries and hospital-acquired infections, and led to sweeping policy changes in the United States. Still, errors that occur when clinicians get a diagnosis wrong or miss them altogether slipped under the radar as the patient-safety movement proliferated. The mistakes may cause an estimated 40,000 to 80,000 deaths a year, according to the Society to Improve Diagnosis in Medicine.

The Doctors Co., a medical liability insurer, has released several reports on the top reasons why its members get sued. Missed and wrong diagnoses are often high on the list.

These realities have refocused attention on diagnostic errors. In August, more than a dozen U.S. healthcare organizations formed a coalition to address the mistakes.

Dr. John Ball, who chaired the Committee on Diagnostic Error in Health Care at the National Academies, says the two BMJ studies speak to the need for improved training on clinical decisionmaking. They also emphasize why teamwork is crucial in the diagnostic process. In both studies, doctors worked autonomously to come up with diagnoses.

“You can't leave it up to a single person,” Ball said. “We need to put in place the things that can limit the effects of our biases, like teamwork and checklists.”

In one of the studies, researchers created six vignettes based on actual patients who had received diagnoses for conditions like pneumonia, pulmonary embolism, meningoencephalitis, hyperthyroidism and appendicitis. A total of 63 family practice residents were given clinical details (sans diagnosis) and a few descriptions of the patient's behavior. The task was to diagnose the condition.

Residents read versions of cases in which patients were depicted as ​making frequent demands, being aggressive, attacking the doctor's competence, having low expectations and ignoring advice. They also reviewed cases where such descriptions were omitted. The residents consistently made more mistakes with the cases of fussier patients.

The second study included 74 internal medicine residents, who also diagnosed cases based on a series of clinical vignettes. The cases were exactly the same except for differences in describing the patients' behaviors. Diagnostic accuracy was once again lower for the more difficult patients.

Furthermore, when asked to recall details at a later time, the physicians were more likely to remember the descriptions of the difficult patients' behaviors than they were to remember the actual clinical details about the case.

The mental effort needed for docs to deal with problematic behavior may distract them from processing clinical information correctly, the study authors said. The study also found that whether the patient was difficult or neutral, clinicians spent about the same amount of time making the diagnosis.

Other experts say the studies are consistent with those suggesting that wording matters. When one clinician hands off a patient to another using phrases like “difficult” or “psychological condition,” bias is triggered, said Dr. Pat Croskerry, director of the critical thinking program at Dalhousie University Health Sciences Center in Halifax, Nova Scotia.

One strategy is to refrain from using disparaging terms during transitions or from mentioning items from the patient's history that are not immediately necessary.

“Simply give objective data that is relevant to the problem at hand,” he suggests. “People think they are helping their colleagues to understand a situation better, but these trigger words have an impact on thinking.”

Other studies support the philosophy that the diagnostic process is better in teams. Clinicians working with partners took about two minutes longer, but were also more accurate in selecting a diagnosis and more confident in their decision than those working alone, according to findings published last year in JAMA.

However, the challenge of teamwork is that not everyone possesses the “necessary candour” needed to ask another for help, notes an editorial accompanying the BMJ findings. The editorial also points out the potential for “group think.”

Computerized diagnostic tools can be helpful “to restore order when a physician's thinking might be disrupted by negative emotions,” wrote Drs. Donald Redelmeier and Edward Etchells of the University of Toronto's Centre for Quality Improvement and Patient Safety.

Experts also note that difficult patients and those who are empowered to be more active in the care they receive are not the same thing. Patients are encouraged to ask questions about their health and seek second opinions when needed, and they have been more actively involved in identifying quality and safety gaps in healthcare.

Overall, the studies indicate that bias can be a real problem in making a diagnosis, said Dr. Mark Graber, founder and president of the Society to Improve Diagnosis in Medicine. He was also a member of a National Academies committee focused on diagnostic error.

While the BMJ analyses look at “difficult” patients, he also warns the pendulum can just as easily swing to the other side. Clinicians can be biased by people they respect, such as friends, family and bosses, and as a result make poor clinical judgments, Graber said.

Croskerry agrees with that assessment regarding caring for family and friends and says “just don't do it.” About five years ago, the trained emergency room physician had an incident where his own son consistently complained of upper respiratory issues. Croskerry encouraged him to shrug it off. But due to his son's persistence, Croskerry finally took him to a local doctor who almost immediately diagnosed his son with mono.

“I had missed it completely,” Croskerry admitted. “Once you have personal relationship with someone it distorts your reasoning. There's good evidence that you cannot look at your friends and family in an objective way.”


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