Medical Errors of Diagnosis Harm More Than Treatment Mistakes

Via: Healthy Skepticism (Facebook Page)

Source: ourhealthcaresucks

CGI image of rod piercing Phineas Gage's skull taken from NINDS public domain page at http://www.ninds.nih.gov/health_and_medical/pubs/tbi.htm (Photo credit: Wikipedia)

Another report on medical errors in America’s healthcare system cautions that these early-stage medical errors account for more medical harm – both preventable deaths and disability – than treatment errors.

In this study, Johns Hopkins researchers reviewed 25 years of medical errors – reflected in medical malpractice payouts – and found that diagnostic errors accounted for more payouts than surgical mistakes or medication overdoses.

Medical errors of improper diagnoses – missed, delayed and wrong diagnoses – accounted for the single largest proportion of such payouts at over a third. And twice as many occurred on an outpatient basis as among hospital inpatients, although the latter were more often lethal (48.4% vs. 36.9%).

The majority were missed diagnoses rather than delayed or wrong diagnoses – and the numbers are vastly understated because they only include those that led to malpractice claims. Most medical errors never reach the point of a malpractice claim.

15-40% Misdiagnoses?

Medical errors is a subject I address in-depth in Our Healthcare Sucks, including the following excerpts:

An estimated 15% of medical diagnoses are in error, with autopsy results showing diagnostic error rates in select areas up to 40%.[1]…

According to an article in The New England Journal of Medicine: [2]

 “125 million (Americans live) with chronic illness, disability, or functional limitation….

“The typical Medicare beneficiary saw two primary care physicians and five specialists (a) year…

“Patients with several chronic conditions may visit up to 16 physicians in a year.”

In a mostly seamless delivery system that emphasized and rewarded coordination of care and avoidance of redundant tests and procedures, maybe it would be possible to maintain quality despite such fragmentation of care.

But the U.S. medical delivery system is anything but “seamless” and, even if it were, it would still require a level of professional precision that’s sorely missing. Physician diagnostic error rates have been estimated as low as 5% (still 1 in 20) and as high as 40% based on autopsy results, with 15% the likely average ballpark.

That’s a huge margin of error that underscores the need to take what your doctor tells you with a grain of salt, at least until you’re able to get it confirmed by another opinion or by imaging or lab test results.

A special Supplement in The American Journal of Medicine [3] addressed this issue with a comprehensive review of the medical literature “Concerning teaching, learning, reasoning and decision making as they relate to diagnostic error and overconfidence”.[4]

According to the authors of this review:

“Being confident even when in error is an inherent human trait, and physicians are no exception. When directly questioned, many clinicians find it inconceivable that their own error rate could be as high as the literature demonstrates…

“This reflects both overconfidence and complacency (emphasis added).”

An article on this report makes this dismal observation:

“Medical practitioners really do not use systems designed to aid their diagnostic decision making…physicians have underutilized decision-support systems and misdiagnosis rates remain high.”

Say It Ain’t So, Doc

Many patients don’t want to believe their doctors are capable of such high rates of medical misdiagnoses – any more than they want to believe our higher rates of medical errors than other developed countries. These are very intelligent, well-educated people, after all – generally more so than the patients they treat. How can such smart people make so many diagnostic errors?

The obvious answer lay in our fee-for-service payment system that penalizes doctors for spending the time required for thoughtful assessments and diagnoses. These “cognitive” services are reimbursed at far lower levels than procedures – whether needed or not.

Medicare and other payers are partly to blame for perpetuating this skewed payment system, as are those in the medical profession who choose to maximize their incomes at their patients’ expense. No one’s forcing them to submit to these skewed incentives, after all. Some don’t, so it’s not impossible – but they’re generally considered either saints or fools by their peers.

Anchoring On First Impressions

But there’s more to our excess medical errors than that. Dr. Jerome Groopman helps us understand how doctors’ training perpetuates mental shortcuts and crutches that contribute greatly to medical errors – and to diagnostic errors specifically. Here’s another excerpt from Our Healthcare Sucks on the subject:

Enter Dr. Jerome Groopman and his New York Times best seller, How Doctors Think, in which he lays out many of the sources of medical error, misdiagnosis, and misjudgment.

He helps us understand how such smart people can make so many mistakes by explaining that it’s not a function of intellect.

Instead, it’s a type of cognitive dysfunction in which many physicians – who are trained and required by their business mandates to make snap judgments – can fall prey to all sorts of errors in thinking.

Here are a few sentences from Dr. Groopman’s book that bear on this discussion:

“Misdiagnosis is different (from medical errors)…experts studying misguided care have concluded the majority of errors are due to flaws in physician thinking, not technical mistakes…

“In one study of misdiagnoses…some 80% could be accounted for by a cascade of cognitive errors…ignoring information that contradicted a fixed notion….

“As many as 15% of all diagnoses are inaccurate…

“Physicians tend to go with their first impression…

“The cognitive mistakes that account for most misdiagnoses…largely reside below the level of conscious thinking (emphasis added).”[5]

Doctors, he explains, tend to get stuck on first impressions, something he calls “anchoring” because it anchors or fixates their diagnosis and often that of other doctors to whom you might be referred.

Or they just might not like certain patients, leading them to cut them off from fully describing their symptoms and settle for the most convenient or available treatment.

If they think the patient is a complainer or hypochondriac, they may assume a benign condition and minimize the likelihood of serious disease.

Now these cognitive flaws, as Dr. Groopman describes them, are all understandable as human failings – and Groopman quite understands them having labored with them himself – but are they professional?

Don’t patients have a right to expect more of their highly-paid doctors?

Why should patients have to worry about whether their doctor likes them or not and fear, quite correctly it seems, that it will bias their treatment?

This isn’t high school, after all.

Defensive Medicine is A Failed Response 

The medical profession has failed to address this crisis in patient safety with the urgency it deserves – opting instead for defensive medicine practices intended to insulate them from malpractice liability rather than address medical errors head-on.

This defensive mindset prevents the profession from engaging more meaningfully to correct both diagnostic and treatment failures.

And with more patients seeking medical care as Obamacare is implemented, doctors will have even less time to spend with patients. The risk of diagnostic errors – and medical errors generally – is likely to increase as a result.

A thorough diagnostic work-up takes time and thought – both of which are in increasingly short supply in America’s broken healthcare system.

All of which means patients will have to learn how to protect themselves and their loved ones when engaging with our fundamentally flawed medical system.

[1] The Autopsy as an Outcome and Performance Measure. Agency for Healthcare Research and Quality. Evidence Report/Technology Assessment. Number 58. Oct. 2002.

[2] Coordinating Care – A Perilous Journey through the Health Care System, The New England Journal of Medicine, Vol. 358:1064-1071, 3/6/08.

[3] The American Journal of Medicine, Volume 121, Issue 5A, May, 2008.

[4] Elsevier Health Sciences (2008, April 29). Will You Be Misdiagnosed? How Diagnostic Errors Happen. ScienceDaily.
[5] How Doctors Think. Dr. Jerome Groopman, Houghton Miflin Company.2007.

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Designing a Smarter Patient

Source: Wall Street Journal - Via Juan Gérvas (list of Seminario Internacional de Atención Primaria: Prevención Cuaternaria) . Barcelona. Octubre 2011

By JEROME GROOPMAN and PAMELA HARTZBAND

Edel Rodriguez

When given clearer information, patients weigh risks and benefits differently from their doctors.

"I'm comfortable with that," or "No, it wouldn't be comfortable for me."

That's what our patients often tell us when faced with a choice about taking a medication or undergoing a procedure. And the discussion usually stops there.

But what makes someone comfortable or uncomfortable with one treatment or another, or with no treatment at all? Where do these views come from? And how can patients make better decisions?

For answers, we spent four years interviewing scores of patients of different ages. We found that a host of powerful and often hidden influences, inside and outside the patient's mind, can sway thinking and distort judgment. We also discovered that, by unmasking those influences, it is possible for patients to gain greater confidence and control over their medical decisions.

Consider the case of Susan Powell (not her real name), a nurse's assistant now in her 50s. She had been healthy all her life, but when she turned 45, she decided to see a primary-care doctor. Susan ate healthy foods and was physically active, but she was a bit overweight, and her blood tests showed that she had high cholesterol. Her doctor prescribed a statin drug and asked her to come back in a month.

Statins are among the most commonly prescribed medications in the world. In the U.S. alone, more than 25 million people take the drugs to lower their cholesterol, which is a key factor leading to heart attack and stroke.

Soon after seeing her doctor, Susan spoke with an acquaintance at church who had developed muscle pain after starting to take a statin. Susan also thought of her father, who had high cholesterol and never took any medication for it. "People take too many pills," he often told his children. He lived a long, full and active life.

Susan decided not to take the statin.

Many people decline treatment because they know someone who suffered from side effects or someone who lived well into old age without treatment. Stories deeply affect all of us, and they can make real the risks and benefits that might otherwise seem abstract—but they can also distort our vision by making the rare appear routine.

Statistics can help to put lessons drawn from stories into a larger context, letting us make a more considered choice than we possibly could by using narratives alone.

At Susan's follow-up appointment a month later, her doctor told her that "by taking a statin pill, you'll reduce your risk of a heart attack over the next 10 years by as much as 30%." The risk of side effects, she continued, was very small, and the benefits far outweighed the risk. Susan promised to give it serious thought.

She continued to search for information, reading everything she could about cholesterol. What caught her eye was a government-sponsored link to a "10-Year Heart Attack Risk Calculator."

She entered her age, total cholesterol number of 240, and "good" cholesterol (HDL) of 37. She was not a smoker, her blood pressure was fine, and she was on no medications. The result: "Risk Score: 1%: Means 1 of 100 people with this level of risk will have a heart attack in the next 10 years."

This means that 99 of 100 people like me won't have a heart attack in the next 10 years, Susan told herself. She started to feel much better. She had found a key number in health literacy: her risk for disease without treatment.

Without treatment, Susan's risk for a heart attack was 1 in 100. If 1 in 100 women has a heart attack, that means 2 in 200 do, or 3 in 300. The statin treatment reduces risk by 30%, or about one-third.

Let's apply that benefit to a group of 300 women like Susan, where three would have a heart attack without taking statins. If we treat them all, we would prevent one heart attack—because we protect one-third of those three. The other two women would still have a heart attack despite taking the medicine. The remaining 297 would not have had a heart attack even without the medication, so they wouldn't benefit from taking it.

This statistic comes as a surprise to many people. When you hear that a statin lowers Susan's risk by 30%, it sounds as if she is at a 100% risk of suffering a heart attack if she doesn't take the medication.

Another component of health literacy is understanding the risks of a therapy. Statins cause muscle pain in 1% to 10% of people who take them. However, if we "flip" the frame, the number without any side effects is 90 to 99 out of 100, a much more reassuring statistic.

Advertisements for drugs may include statistics, but fundamentally these ads are designed to communicate a compelling tale. Over the weeks that followed her appointment with her physician, Susan paid particular attention to ads for statins. Once she started looking for them, they seemed to be everywhere.

In 2007, a team of researchers from the UCLA Medical Center and other medical centers studied prescription drug ads broadcast on national networks. They found that the average American TV viewer sees over 1,000 prescription drug ads in the space of a year. That's 16 hours all told—much more time than the average person spends with his or her primary-care physician.

The study concluded that the large majority of TV ads fail to fulfill an educational purpose. But they clearly work, at least from the point of view of sales: Every $1,000 spent on advertising translated into 24 new prescriptions, according to an analysis by the House Energy and Commerce Committee.

Another illuminating study, conducted by researchers at the Dartmouth Institute for Health Policy and Clinical Practice, examined the impact of printed drug ads on patient preferences. One group was given actual ads. A second group received the same ads, except that the brief summary at the end of the text was replaced by a "drug-facts box." The box presented information in a clear, accessible fashion, similar to the way we recalculated the benefits and risks of a statin for Susan.

The results of the Dartmouth research are impressive. Nearly two-thirds of the group that saw the original ads overestimated the benefits of the treatment. They believed it was 10 times more effective than it actually was. But nearly three-quarters of the participants who saw the information in the drug-facts box correctly assessed the actual benefits of the treatment.

Even more striking was another finding. When people were given readily understandable information about the statin's actual benefit in preventing future heart disease, nearly twice as many said they wouldn't take the drug in light of its side effects. When given clearer information, the patients weighed the risks and benefits differently from their doctors and were less likely to take the medication.

Susan Powell's decision was not simple. More than five years later, her doctor continues to encourage her to take the drug, and she continues to say no—but now, at least, she can more fully explain why.

—Dr. Groopman and Dr. Hartzband are on the faculty of Harvard Medical School and the staff of Beth Israel Deaconess Medical Center, both in Boston. This essay is adapted from their new book, "Your Medical Mind: How To Decide What Is Right for You.

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