Fifteen years ago, my teenage son Lewis went to the hospital for an elective surgical procedure. After the operation, his doctors failed to notice that he was suffering from an undetected infection and blood loss from an ulcer caused by pain medication. They believed his symptoms were an indication of constipation from other pain medications he was taking. This mistake cost my son his life—he died four days after entering the hospital. Now: I teach patients skills that can help them avoid a similar tragedy.
A groundbreaking new report from the prestigious Institute of Medicine (IOM) concluded that most Americans will experience at least one diagnostic error—that is, an inaccurate, missed or delayed diagnosis, as determined by later definitive testing—at some point in their lives.
The IOM report called diagnostic errors a “blind spot” in the delivery of quality health care. Each year, about one in 20 patients who seek outpatient care will suffer from a wrong or delayed diagnosis. According to autopsy studies, diagnostic mistakes contribute to about 10% of patient deaths. Unfortunately, diagnostic errors haven’t gotten as much attention as treatment and surgical errors—for example, operating on the wrong body part—partially because the latter are easier and quicker to identify. Now patient-safety experts are taking steps to better understand why diagnostic errors occur. Key reasons…
• Tests help—and hurt. Patients may be given a staggering number of tests—X-rays, blood tests, biopsies and more. The process of ordering, conducting and conveying the results of a test, however, can be complex and poorly organized.
• Poor communication. Can you count on the internist to talk to the nurse? Will the radiologist convey all of the pertinent information to the surgeon? Don’t count on it. Patients also play a role. They should tell their doctors about all the symptoms they’re having and whether they’re getting better or worse after starting a new treatment.
• Snap judgments. Doctors often develop a working diagnosis within the first few minutes of hearing the patient’s reported symptoms. The danger is that doctors can develop a so-called anchoring bias that leads them to cling to their initial diagnosis and prevents them from fully considering new information or looking for other possibilities.
Major medical groups, including the Society to Improve Diagnosis in Medicine, have identified a number of institutional factors—such as stronger teamwork—to reduce errors. But no one has more at stake in these situations than the patients themselves. Four steps you can take to avoid a misdiagnosis…
STEP 1: Organize your thoughts. Most of the time, doctors have only 15 minutes with each patient, so you need to make the most of your time together. Plan ahead: Your medical history—including a description of symptoms and when the problem started—is the most important part of an exam. Describe the nature and context of your symptoms in as much detail as you can. When do you feel them? What makes them worse or better? Why are you worried? Keep it concise and on topic, but include your own thoughts so the doctor can address the issues that concern you.
My advice: If possible, before you see the doctor, use the Internet to investigate your symptoms and the likely causes. Your findings should not be used to challenge your doctor, but rather as a way to have a more informed conversation. If you don’t have confidence in your own abilities to do research, take advantage of a service like Expert HealthSearch, a free service that puts you in touch with a medical librarian who can search the literature for you.
STEP 2: Don’t be afraid to question test results. They are more prone to error than most people imagine. In one study, experts who reviewed biopsies of more than 6,000 cancer patients concluded that 86 had been given a wrong diagnosis. Samples can be too small or even contaminated…technicians can make mistakes…and there can be false-negatives or false-positives. Results can be misinterpreted, or even more often, they can go unreported to the patient.
My advice: If a test result seems to fly in the face of the symptoms you are experiencing, consider asking to repeat the test or have a second doctor review it. And never assume that no news is good news. Follow up to be sure that your test results have been received and reviewed and that you know what they are.
STEP 3: Ask about alternatives. Many common symptoms—such as fatigue, muscle aches and abdominal pain—are known as nonspecific symptoms. They can be caused by dozens of conditions.
My advice: To help understand your doctor’s thinking, ask him/her this question: Could you please explain your differential diagnoses? This is a list of possible diagnoses ranked in order of likelihood. It’s a thought process that helps a diagnostician avoid overlooking any likely possibilities. The most serious conditions on the list should be ruled out before settling on a less serious diagnosis, and the doctor should be looking for causes and not just treating symptoms.
What to ask: If there is any question about a diagnosis, patients can help assess the “fit” by asking three important questions: Does this diagnosis match all my symptoms? What else could it be? Could there be more than one thing going on?
STEP 4: Don’t skip the second opinion. I cannot stress this enough. In the study of cancer patients cited earlier, Johns Hopkins University researchers found that one to two of every 100 who got a second opinion with definitive testing after a tumor biopsy had gotten a wrong diagnosis the first time.
My advice: It’s not always possible to get a second opinion—sometimes in medicine you have to move fast. But if you can, a second (or even a third) opinion is smart when symptoms seem severe…if your doctor is recommending surgery…or if you are told that you have a rare or fatal condition. Check first, but usually insurance will pay for a second opinion. Outside of emergencies, most of the time a brief delay in treatment while you get a second opinion will not affect your outcome.
