For a physician to deliver an accurate diagnosis, it requires time for thoughtful consideration of a patient's symptoms.
But time is one element physicians say they don't have these days as they scramble to maximize patient throughput, an unfortunate side effect of a payment system still dominated by fee-for-service medicine.
The growing constraints on physician time have emerged as a major cause of missed or wrong diagnoses, experts say. And those errors account for about 1 in 6 incidents of system-induced patient harm, which causes more than 100,000 deaths a year, according to some estimates.
While the U.S. patient-safety movement has focused enormous attention on medical errors over the past few decades, diagnostic errors have received less attention from practitioners, the research community or patient-safety advocates. The extent of the problem is hard to assess as missed diagnoses remain a largely unreported phenomenon.
The Institute of Medicine, which first called attention to the extent of the patient-safety problem, barely mentioned diagnostic errors in its historic 1999 To Err Is Human report. But now it is finally tackling the issue.
The IOM will issue a report this year that will raise a red flag over the issue and give advocates the intellectual firepower needed to get more resources focused on this cause of patient harm.
One out of every 20 U.S. adults could be misdiagnosed during outpatient visits, and about half of those errors could prove to be harmful, according to recent estimates. “Everybody assumed we were doing OK, but the facts are very different,” said
Dr. Mark Graber, founder and president of the Society to Improve Diagnosis in Medicine and a member of the IOM committee writing the upcoming report. Missed diagnoses “are probably one of the most common patient-safety problems. But virtually nobody is working on it,” he said.
About 12 million U.S. adults every year experience a diagnostic mistake. But little is understood about the factors leading to those incorrect, delayed or missed diagnoses. The factors can include lapses in clinical judgments by the physicians or a breakdown in communication between providers.
One needn't look far to understand why missed diagnoses are rarely reported. Physicians are reluctant to report their mistakes because of fear of litigation. Major medical malpractice cases with big settlements sometimes arisde from missed diagnoses.
Also, there is no widely accepted definition of what constitutes a diagnostic error. This represents a challenge for researchers who want to study the problem.
But in the few studies that have looked at the issue, high caseloads and rushed schedules are a recurring theme. At Maine Medical Center, a part of MaineHealth in Portland, the hospital's patient-safety officer and clinical educator initiated a pilot project that ran from January to July 2011 where internal and family medicine, critical-care and emergency room doctors voluntarily shared examples of diagnostic mistakes.
Over the six-month period, the team found 36 instances where diseases such as cancer, stroke and pneumonia were either missed, misdiagnosed or not identified in a timely fashion. “Just about every time you talk to clinicians involved in diagnostic errors, it seems like time and volume is an issue,” said Dr. Robert Trowbridge, an internal medicine physician who teaches clinical reasoning at Maine Medical Center.
When time or resources are limited, all people including physicians rely on mental shortcuts or heuristics, an abbreviated way of thinking. That can lead physicians to make quick assumptions and introduce cognitive bias. This not only increases the likelihood of missing disease warning signs, but leads to poorer quality decisions.
Though expediting decisions may not always cause a problem, “it will inevitably fail some patients,” said Dr. Patrick Croskerry, an emergency medicine professor who directs the critical thinking program at Dalhousie University in Halifax, Nova Scotia. He is also on the IOM committee. “The normal checks and balances built into the decisionmaking process may not be executed.”
Dr. Gordon Schiff, who practices general internal medicine at Brigham and Women's Hospital in Boston, often worries about time. He said that he may have only 15 minutes with patients, and within that time, only three minutes is spent ruminating on the information obtained.
“I wish I had 22 minutes for every patient to stroke my beard and think about what the patient's condition could be,” Schiff said. “But a lot of that opportunity is being squeezed out of the encounters.”
The fee-for-service reimbursement system, where physicians are paid a set price for every encounter, gets a large share of the blame. It leads to what some call the “treadmill effect,” where providers feel the need to squeeze in every possible patient to get the reimbursement needed to cover overhead costs.
While the nation is gradually transitioning toward rewarding value instead of volume, most clinicians “have a foot in both canoes right now,” said Dr. Nirmal Joshi, chief medical officer of PinnacleHealth System, Harrisburg, Pa.
Payment reform clearly has to be a part of the fix, said Dr. Reid Blackwelder, immediate past president of the American Academy of Family Physicians. One of the challenges in the fee-for-service system is that physicians practice what he calls “chart care” instead of patient care. “In the absence of payment reform, it's hard to tell physicians to have more time.”
To tackle misdiagnoses, a few healthcare systems encourage physicians to open up about errors and the factors that caused them. They want to know what factors beyond time are leading to poor decisionmaking.
They are being pushed by studies conducted by medical malpractice insurers, which can wind up making large payouts on cases that hinge on misdiagnoses. “Malpractice insurers are not letting us forget,” Schiff said. “It's costing them a lot of money.”
A 2014 report by CRICO Strategies, a Cambridge, Mass.-based risk-management group, found that about 20% of 23,527 medical malpractice cases filed between 2008 and 2012 were related to diagnostic concerns. About 73% of the 4,705 diagnostic claims alleged lapses in clinical judgment, such as failure to order diagnostic tests, establish a differential diagnoses or give a referral.
