Healthcare professionals are focused on providing quality care. Outside support such as medical transcription services allow physicians to focus on what they do best – caring for their patients. However, diagnostic errors that harm patients can happen and sadly, is a common problem. A Johns Hopkins study of U.S. malpractice claim payouts found that diagnosis- related payments amounted to $38.8 billion between 1986 and 2010. According to the researchers, diagnostic errors made up the largest portion of claims, the most severe patient harm, and the highest total of penalty payouts.
There are many causes of diagnostic errors:
- Flaws in clinical reasoning: Diagnostic biases or inaccurate beliefs affect decision-making. Physicians often rely on heuristics(“rules of thumb”) to reach a provisional diagnosis, especially when the patient has common symptoms. Cognitive biases include:
- Availability heuristic – Diagnosis of current patient biased by experience with past cases or referring to what comes to mind most easily
- Anchoring heuristic – Sticking with a diagnosis. For instance, when a patient does not respond to treatment, this type of bias would lead the physician to order a stronger dose or a different formulation of a previously prescribed medication instead of considering another diagnosis
- Framing – Assembling elements that support a diagnosis
- Blind obedience – Relying on another physician’s opinions, where an agreement is reached based on an authoritative source (such as laboratory and imaging test results) without adequate examination.
- Omissionbias – Placing excessive emphasis on avoiding the adverse effects of a therapy, which leads to under-utilization of a beneficial treatment.
Poor teamwork and communication: Communication breakdowns among clinicians have been identified a potential reason for diagnostic errors, especially in emergency medicine and surgery (www.psnet.ahrq.gov). A study published in the journal Diagnosis reported that communication problems related to diagnostic testing may be the reason for nearly half of all errors made by in typical primary care practices. According to the researchers, communication failures between radiologists, referring clinicians, and patients can lead to critical information not being conveyed, leading to delayed or missed diagnosis.
- Lack of reliable systems for common outpatient clinical situations: The Agency for Healthcare Research and Quality (AHRQ) points out that lack of proper mechanisms for triaging acutely ill patients by telephone and following up on test results, also increases the chances of diagnostic error. A study published by the AHRQ that analyzed telephone-related closed malpractice claims from a large insurance company database found that, in most cases, clinicians failed to accurately diagnose the patient. Errors leading to misdiagnosis included inadequate documentation, faulty triage, and lack of protocols for handling telephone calls.
- Overconfidence: A recent MD magazine report authored by a surgeon points to overconfidence as a physician trait that can lead to misdiagnosis. The author says that overconfidence can lead to several mental traps that can lead physicians to make misdiagnosis and errors. Physicians should keep in mind that the first diagnosis that comes to mind may not be the right one. “I often change my mind during the interview about the diagnosis, as I grow more confident in what I am hearing. As a result, I order far fewer tests, scans, and drugs than I used to,” he says.
- “The VIP Syndrome”: The MD magazine also highlights the VIP Syndrome as a reason for diagnostic errors. The VIP Syndrome is when the physician is intimidated or is unwilling to recommend things which may be unpleasant for their patient. This will lead to either over treatment or under treatment because of cognitive errors on the part of physicians who want to gratify their celebrity patients.
To reduce incidence of diagnostic errors, physicians should avoid arriving at a final analysis or judgment based on the initial information provided by the patient. It is also important not to connect symptoms to similar complaints experienced by other patients. Clinicians should also not let stereotypes interfere with clinical judgment or be in a hurry to come to a conclusion.
The new business model in modern medicine is one of the factors that have reduced the time that physicians have with their patients, leading to missed diagnosis. Medical transcription outsourcing is a viable strategy to deal with EHR- related documentation concerns. However, EHRs contain direct questions which must be check marked in the correct boxes, preventing clinicians from listening, thinking intuitively, and coming to a diagnosis based on experience. Awareness about these problems can help providers avoid diagnostic errors to a great extent.