Diagnosing the Problem
“The delivery of health care has proceeded for decades with a blind spot: Diagnostic errors—inaccurate or delayed diagnoses—persist throughout all settings of care and continue to harm an unacceptable number of patients. For example:
- A conservative estimate found that 5 percent of U.S. adults who seek outpatient care each year experience a diagnostic error.
- Postmortem examination research spanning decades has shown that diagnostic errors contribute to approximately 10 percent of patient deaths.
- Medical record reviews suggest that diagnostic errors account for 6 to 17 percent of hospital adverse events.
- Diagnostic errors are the leading type of paid medical malpractice claims, are almost twice as likely to have resulted in the patient’s death compared to other claims, and represent the highest proportion of total payments.”1
“The [Committee on Diagnostic Error in Health Care] definition of diagnostic error is the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient….
Timeliness means that the diagnosis was not meaningfully delayed; however, timeliness is context-dependent. While some diagnoses may take days, weeks, or even months to establish, timely may mean quite quickly (minutes to hours) for other urgent diagnoses. A diagnosis is not accurate if it differs from the true condition a patient has (or does not have) or if it is imprecise and incomplete.”1
Source: Institute of Medicine
The 2015 Institute of Medicine (IOM) publication “Improving Diagnosis in Healthcare” takes an important step in the right direction with respect to identifying and avoiding medical error.1 I suspect many have adopted this document in toto based on its credible source and its premise of improving diagnostic accuracy in medicine. I do agree that the IOM has produced another powerful and important document overall, but I feel it did so, to a certain degree, at the expense of emergency medicine.
What I think is being missed in this whole discussion is that as more pressure is placed on diagnosing accurately and in a “timely” manner, the more likely we are to become experts at creating diagnostic error. Although diagnostic error expert Patrick Croskerry, MD, PhD, professor of emergency medicine at Dalhousie University in Halifax, Nova Scotia, and his work were both included in this paper, aren’t the heuristics, mental shortcuts, that Dr. Croskerry and others caution us to avoid only amplified by this additional pressure?
The IOM has clearly identified the emergency department as a high-risk environment. I certainly can’t disagree. However, from my perspective, an overemphasis has been placed on the ED, suggesting an overgenerous share of responsibility belongs to emergency physicians. As a matter of fact, the emergency department is mentioned no fewer than 48 times in its 369-page document. “For example, analyses of claims data could be used in ‘look back’ studies to identify the frequency with which acute coronary syndrome is misdiagnosed … explore how frequently these beneficiaries were seen by health care professionals in the week prior to ultimate diagnosis (either in outpatient, emergency department, or hospital settings), the incorrect diagnoses that were made, and the factors associated with the diagnostic error.”1 I don’t dispute that the ED should be involved in such programs, but I do question why others are omitted. Isn’t the ED an outpatient department, and aren’t most EDs part of a hospital? Then why is the ED singled out while other outpatient and hospital departments are not even mentioned?
Topics: DiagnosisEmergency DepartmentEmergency MedicineEmergency PhysicianInstitute of MedicineMedical ErrorQuality
About the Author
Kevin M. Klauer, DO, EJD, FACEP, is Chief Medical Officer–hospital-based services and Chief Risk Officer for TeamHealth as well as the Executive Director of the TeamHealth Patient Safety Organization. He is a clinical assistant professor at the University of Tennessee and Michigan State University College of Osteopathic Medicine. Dr. Klauer served as editor-in-chief for Emergency Physicians Monthly publication for five years and is the co-author of two risk management books: Emergency Medicine Bouncebacks: Medical and Legal and Risk Management and the Emergency Department: Executive Leadership for Protecting Patients and Hospitals. Dr. Klauer also serves on the ACEP Board.
View this author's posts »
6 Responses to “Opinion: Institute of Medicine Report on Medical Misdiagnoses Overly Critical of Emergency Medicine”
February 7, 2016
Jerry W. Jones, MD FACEP FAAEMWhile I do agree with Dr. Klauer that it appears emergency medicine was unjustifiably singled-out ion this study, I would like to add a few observations over 35 years of practicing emergency medicine.
It is an ideal situation if the ED physician is able to arrive at a diagnosis in an efficient and timely manner. Unfortunately, the human machine is not always willing to cooperate and in many cases a definitive diagnosis simply cannot be achieved in the ED within a reasonable time-frame. The next issue for the ED physician becomes “Do I admit or do I refer?” A physician who has listened to the patient’s story – and I don’t mean asked 6 or 7 preconceived “Yes/No” history template questions that “best fit” (but don’t EXACTLY fit) the patient’s chief complaint – has done a focused physical examination – not just the now-ubiquitous “stethoscope tap” chest exam or “momentary palm touch” abdominal exam, formulated a differential diagnosis that is followed, has ordered appropriate lab and imaging tests based on his/her assessment of the patient, reviewed all tests results and addressed any unexpected results, is going to be much more secure in deciding whether a patient with an undiagnosed condition needs emergency admission or simply follow-up with their own physician or a referral specialist.
However, in the last 15-20 years I have noted a serious and progressive decline in the ability of the average emergency physician to perform a competent history and physical exam. In this day of the EHR, many patients have physical exams recorded that never took place. I recall (I’m semi-retired now) medical students and residents arriving for their emergency department rotations without even a stethoscope. I can’t speak as to whether these same deficiencies apply to other specialties, though I suspect they do. We need to take a closer look at how medical students are being taught and instill in all new physicians and physicians-in-the-making that there is more to medicine than ordering a bunch of tests and then trying to explain away – or in some unfortunate cases – simply ignore the unexpected, for no other reason than it doesn’t fit our preconceived notion of diagnosis and/or disposition.
December 25, 2016
N. Newman, M.D., FACEPI could not agree with you more. Rapid efficiency does not necessarily equate to quality of care. So much of emergency medicine is what I refer to as “knee jerk” or “cookie cutter” medicine. The formulation of an immediate diagnosis(even before the cursory physical exam and history taking) followed by the requisite lab and imaging studies. Although some patients are quickly assessed and a correct diagnosis made, some patients require a bit more time. Many times I have taken a history from a patient with what appears to be a simple complaint only to discover that the complaint is more complicated. Personally, I have discovered that as patients “warm” to me, they open up and the details of their complaint are offered. The pressure I experience at times for being less speedy than my colleagues can be tremendous. Because it affects departmental metrics. Although meticulous in my history-taking, physical exam(I insist that patients be undressed) and ordering only what I need for my focused exam, and add what may become necessary later, there simply is no acknowledgment for that type of responsible practice. Only criticism. Fortunately, my patients do recognize my commitment to them and as a result, I have very minimal patient complaints, even from difficult patients.
Despite the requirement of certain ER groups for its ER physicians to complete compliance courses in diagnoses with the highest likelihood of being misdiagnosed or suggesting CME’s in High Risk Emergency Medicine, it is as if we are going through the motions. Ironically, the nature of EHR’s, compliance heavy hospitals and ER departments make it difficult for one to be a true clinician to avoid these pitfalls in emergency medicine. “You’re damned if you do, you’re damned if you don’t”…..
Simply put, the art of medicine is becoming lost in the interest of rapid efficiency. I sincerely have empathy for the new physicians who have less appreciation of this art through no fault of their own. I made a decision years ago to reprioritize and maintain my skill as a clinician: Patients first, documentation second(protect myself and my license) and speed third. It has held me in good stead resulting in minimal patient complaints and no lawsuits for 21 years. Most importantly, I’m happy, as are my patients.
February 7, 2016
P David Cash MD FACEPUntil the Institute of Medicine publishes the names, location, and causes of death of the 100,000 patients per year it alleges physicians kill, I will continue to view any information that this organization provides as absolute garbage.
February 7, 2016
William FranklinEmergency Medicine has its own language and culture. People who don’t practice emergency medicine think it’s just internal medicine in the ER. They picture us having the same leisures they have in how they manage patients, i.e. linearly managing patients with known diagnoses. They will never learn our culture or language because they don’t necessarily even recognize that there is a difference. Like most people, they don’t go looking for things they don’t know are in existence. As such, we will always be misunderstood, I fear.
I have seen positive changes in the way we are perceived over my 20 years of practice, but there is still a way to go. I explain it as thus: Our job is to manage a community resource, the emergency department. Manage is the key word. Everybody else in medicine has the job of managing the patient’s illness. We do that to the extent possible in the background of managing a community resource, but we are never relieved of our duty to first manage a community resource. We co-manage several patients at a time, providing safety for the downstream docs to do their work with major and unexpected medical conditions identified, treated, or ruled out….and like, 5 minutes ago.
We speak a language that nobody else in medicine speaks. Like anybody in that situation, we often can only shake our heads “yes” and move on.
February 7, 2016
Myles Riner, MDLet’s call a spade a spade: the authors of this IOM report let their own prejudices and suppositions distort and misinterpret the evidence, resulting in a misdiagnosis of the problem of diagnostic errors and its causes and impacts on emergency department patients.
February 10, 2016
Hijinio Carreon DO FACEPI believe your comments are right on point with what we as a specialty need to be more outspoken of. The video that IOM created for laypeople (https://m.youtube.com/watch?v=fStBWT6fa3E), is a mockery to physician insight and perception that we would only favor one diagnosis and do not communicate with our patients throughout their hospitalization. The woman with left upper extremity pain that was apparently anginal in nature, states that her long-term morbidity is associated to the delay in her diagnosis. However, they fail to mention if she may have reported any other symptoms to the emergency physician evaluating her on that given day, that may have led him/her to believe that this could be acid reflux. Further, did her symptoms evolve over those two weeks and manifest into more obvious anginal symptoms? If we admitted every chest pain that would be considered clinically low risk, what are the long-term implications to our healthcare system? If we admitted every patient that stated they have a “high pain tolerance” and know that something is wrong, what do we further due to our growing narcotic epidemic? Yet, we find more ways to burden our specialty in reflecting on delays in diagnosis and pointing fingers for the growing narcotic epidemic.
We have all recently been asked to meet the CMS standards for severe sepsis in all of our patients. However, what about the patients in our respective institution that ultimately do not have sepsis? It may appear they could have an infection but for fear of not meeting regulatory standards, still received the 30 ML per kilo bolus and broad spectrum antibiotics. Maybe the patient even had a lactic acidosis, and an interstitial infiltrate that was could reflect pneumonia. What are the implications and long-term morbidity and mortality associated with these patients, that we now have been asked to ensure we hit all quality metrics within a three hour window (just click the sepsis bundle and everything will be taken care of – but the patient)? Did we not learn from the pneumonia initiative, requiring initiatives such as these have negative implications? However, when a patient is negatively impacted because a physician attempted to use his critical decision-making and determine appropriate line of action, he immediately will be referred back to the CMS standards and the IOM initiative and be asked why.
I thought the best statement I heard made at SMACC was protocolized therapy makes stupid people stupider and smart people stupid. Yes, cognitive errors occur in every specialty and each specialty needs to be accountable. Better communication between physicians and physician sub specialties needs to occur, enhancement of our medical school education etc. We need to stop focusing on certain hospital metrics. We need to allow an illness to manifest and focus on patient care!