More on diagnostic errors

by rcentor on June 11, 2008

I have been writing about the importance of accurate diagnosis throughout the 6+ years of this blog’s existence. I frequently opine that the quality movement has ignored diagnostic accuracy because it is not easily measured.

Maggie Mahar tries to address this issue in two recent blog entries – The Silence Surrounding Diagnostic Errors; Part I and The Silence Surrounding Diagnostic Errors; Part II. She does a credible reporting job, but misses a feel for the issue. She has read articles, and can even cite data, but she has not experienced the diagnostic process. She gets a B for effort.

I agree with her that diagnostic error deserves much more prominence. Do a search on diagnosis on this blog, and you will find results galore. I want to highlight my concluding piece of 2007 – db’s medrants 2007 considered – the year of quality – in which I said:

For me the most important concept is that the high quality physician thinks. Jerome Groopman wrote skillfully about this topic in his book – How Doctors Think? Here is one of many entries that I made relevant to that book – Crichton on Groopman

I believe that the big message of this book comes from the 3rd word of the title. Doctors must think. Thinking is our forte and our raison d’être. Patients come to us for answers. They expect us to figure out what the problem really is.

Unlike some of my colleagues I do not believe that we should emphasize management of chronic illness. Management of chronic illness follows from complete diagnosis. When I use the word diagnosis here I am referring to this definition: a determining or analysis of the cause or nature of a problem or situation.

Physicians make disease diagnoses, but we also diagnosis the patient’s social context, the impact of multiple diseases, and their belief systems. Designing a management strategy requires a complete diagnosis of the patient who has the disease(s).

I praise Groopman because he champions the role of physician thinking. I agree.

Now thinking takes time. We can not do high quality medicine if we do not have and take enough time with each patient. Quality health care requires time. Yet our current reimbursement system incents physicians to keep visits short, and substitute testing or consultation for thinking.

Until our payment system values correct diagnosis and pays us to think, we will continue to have diagnostic errors. Now some errors are almost unavoidable. Diagnosis is the cornerstone of excellent medicine, and yet we have complex plans for giving bonuses for management tasks. As Wachter said this week:

As the quality and safety movements gallop along, the need to fix Diagnostic Errors Exceptionalism grows more pressing. Until we do, we will face a fundamental problem: a hospital can be seen as a high quality organization – receiving awards for being a stellar performer and oodles of cash from P4P programs – if all of its “pneumonia” patients receive the correct antibiotics, all its “CHF” patients are prescribed ACE inhibitors, and all its “MI” patients get aspirin and beta blockers.

Even if every one of the diagnoses was wrong.

Now Maggie Mahar believes that one of the problems is the autopsy rate. Most diagnostic errors do not immediately result in death. This problem is much more pervasive.

We continue to have a health care payment system that rewards procedures – surgery, invasive cardiology, radiology, etc. These are wonderful necessary adjuncts to great medicine. But great medicine always follows from accurate, timely diagnosis. We must reward the excellent detectives.