Diagnostic Skepticism – the most valuable trait

As a regular internal medicine ward attending, I see diagnostic errors frequently.  Sometimes the patients have received an incorrect label from the emergency department; sometimes another internist or subspecialist has provided the wrong label; sometimes their primary care physician has mislabeled the diagnosis.

While many diagnostic errors are challenging to assess, we still see errors that only require one attribute – diagnostic skepticism.  Diagnostic skepticism is a learned trait.  We usually learn it after we have made our own errors.  We make errors by believing an existing label and not questioning that label.

Over the years I have become increasingly skeptical about diagnoses.  We have an obligation to always think carefully about whether the diagnosis makes sense.

One major problem with the performance measurement movement is that it ignores diagnosis.  But without correct diagnosis, treatment assessments are meaningless.  I have seen several patients treated perfectly for systolic dysfunction, but alas they really had obstructive sleep apnea, COPD and pulmonary hypertension.  They received perfect treatment for the wrong disease.  And there physicians and the hospital received credit for those treatments.  But the patient needed a correct diagnosis.

Community acquired pneumonia represents another diagnosis that too often is incorrect.  Pharyngitis is too often labeled viral just because the rapid strep test is negative.

Yesterday I saw a patient who carried the label of COPD, but the story made not sense.  We see this several times a year.  In fact this patient has restrictive lung disease.

We have an obligation to second guess diagnoses.  Accepting a diagnosis without some thought allows us to make errors.  If you are not already a diagnostic skeptic, please become one.