Will You Be Misdiagnosed? – How Diagnostic Errors Happen

Physician Overconfidence Explored as a Contributing Factor

New York, April 28, 2008 – How frequently do doctors misdiagnose patients? While research has demonstrated that the great majority of medical diagnoses are correct, the answer is probably higher than patients expect and certainly higher than doctors realize. In a Supplement to the May issue of The American Journal of Medicine, a collection of articles and commentaries sheds light on the causes underlying misdiagnoses and demonstrates a nontrivial rate of diagnostic error that ranges from <5% in the perceptual specialties (pathology, radiology, dermatology) up to 10% to 15% in many other fields.

The sensitive issue of diagnostic error is rarely discussed and has been understudied. The papers in this volume confirm the extent of diagnostic errors and suggest improvement will best come by developing systems to provide physicians with better feedback on their own errors.

Guest Editors Mark L. Graber, MD, FACP (Veterans Affairs Medical Center, Northport, NY and Department of Medicine, SUNY Stony Book) and Eta S. Berner, EdD (School of Health Professions, University of Alabama at Birmingham) oversaw the development and compilation of these papers. Drs. Berner and Graber conducted an extensive literature review concerning teaching, learning, reasoning and decision making as they relate to diagnostic error and overconfidence and developed a framework for strategies to address the problem.

They write, “Given that physicians overall are highly dedicated and well-intentioned, we believe that if they were more aware of these factors and their own predisposition to error, they would adopt behaviors and attitudes that would help decrease the likelihood of diagnostic error. …Being confident even when in error is an inherent human trait, and physicians are no exception. The fact that most of their diagnoses are correct, and that effective feedback regarding their errors is lacking, reinforces this inclination. When directly questioned, many clinicians find it inconceivable that their own error rate could be as high as the literature demonstrates. They acknowledge that diagnostic error exists, but believe the rate is very low, and that any errors are made by others who are less skillful or less careful. This reflects both overconfidence and complacency. …In medicine, the challenge is to reduce the complacency and overconfidence that leads to failure to recognize when one’s diagnosis is incorrect.”

Dr. Pat Croskerry and Dr. Geoff Norman review two modes of clinical reasoning to understand the processes underlying overconfidence. Ms. Beth Crandall and Dr. Robert L. Wears highlight gaps in knowledge about the nature of diagnostic problems, emphasizing the limitations of applying static models to the messy world of clinical practice.

In any endeavor, "Learning and feedback are inseparable," according to Dr. Gordon L. Schiff, who discusses the numerous barriers to adequate feedback and follow-up in the real world of clinical practice. Taking another approach, Dr. Jenny W. Rudolph and Dr. J. Bradley Morrison provide an expanded model of the fundamental feedback processes involved in diagnostic problem solving, highlighting particular leverage points for avoiding error. In the final commentary, Dr. Graber identifies stakeholders interested in medical diagnosis and provides recommendations to help each reduce diagnostic error.

These papers also emphasize a second theme. Medical practitioners really do not use systems designed to aid their diagnostic decision making. From early systems in the 1980s to more recent efforts, physicians have underutilized decision-support systems and misdiagnosis rates remain high.

Donald A.B. Lindberg, MD, Director of the National Library of Medicine, writes in an introduction to the Supplement, “I sympathize with and respectfully salute these present efforts to study diagnostic decision making and to remedy its weaknesses…I applaud especially the suggestions to systematize the incorporation of the ‘downstream’ experiences and participation of the patients in all efforts to improve the diagnostic process.”

“In my view, diagnostic error will be reduced only if physicians have a more realistic understanding of the amount of diagnostic errors they PERSONALLY make,” summarizes Paul Mongerson, who created a foundation to promote computer-based and other strategies to reduce diagnostic errors. “I believe that the accuracy of diagnosis can be best improved by informing physicians of the extent of their own (not others) errors and urging them to personally take steps to reduce their own errors.”

The Supplement appears in The American Journal of Medicine, Volume 121, Issue 5A (May 2008) published by Elsevier. This supplement was sponsored by the Paul Mongerson Foundation through the Raymond James Charitable Endowment Fund. Many of the ideas expressed here emerged from discussions at a meeting among the authors in Naples, Florida, in December 2006 that was sponsored by the University of Alabama at Birmingham with support from the Paul Mongerson Foundation.

Drs. Berner and Graber will be co-directing the first national conference focusing on diagnostic errors in medicine, May 31- June 1, 2008 in Phoenix, AZ. The conference is co-sponsored by the Agency for Healthcare Research and Quality and the American Medical Informatics Association. The program includes leaders in this field including the authors of the papers in this supplement. See http://www.amia.org/meetings/s08/dem.asp.


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Full text of the articles featured is available upon request. Contact ajmmedia@elsevier.com to obtain copies. To schedule an interview with Dr. Berner contact Bob Shepard, UAB media relations, 205-934-8934 or bshep@uab.edu. For Dr. Graber contact Joe Sledge, Public Affairs Officer, 631-266-6074 or joe.sledge@va.gov.


The American Journal of Medicine
Supplement: Diagnostic Error: Is Overconfidence the Problem?
Volume 121, Issue 5A (May 2008)
Guest Editors
Mark L. Graber, MD, FACP
, Veterans Affairs Medical Center, Northport, NY and Department of Medicine, SUNY Stony Book, Stony Brook, NY
Eta S. Berner, EdD, Department of Health Services Administration, School of Health Professions, University of Alabama at Birmingham


Foreword
Paul Mongerson

Introduction
Donald A.B. Lindberg

Overconfidence as a Cause of Diagnostic Error in Medicine
Eta S. Berner and Mark L. Graber

Overconfidence in Clinical Decision Making
Pat Croskerry and Geoff Norman

Expanding Perspectives on Misdiagnosis
Beth Crandall and Robert L. Wears

Sidestepping Superstitious Learning, Ambiguity and Other Roadblocks: A Feedback Model of Diagnostic Problem Solving
Jenny W. Rudolph and J. Bradley Morrison

Minimizing Diagnostic Error: The Importance of Follow-Up and Feedback
Gordon D. Schiff

Taking Steps Towards a Safer Future: Measures to Promote Timely and Accurate Diagnosis
Mark L. Graber

About the American Journal of Medicine
The American Journal of Medicine, known as the “Green Journal,” is one of the oldest and most prestigious general internal medicine journals published in the United States. AJM, the official journal of The Association of Professors of Medicine, a group comprised of chairs of departments of internal medicine at 125-plus U.S. medical schools, publishes peer-reviewed, original scientific studies that have direct clinical significance. The information contained in this article in The American Journal of Medicine is not a substitute for medical advice or treatment, and the Journal recommends consultation with your physician or healthcare professional. AJM is published by Elsevier.

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