To Err at the Outset
It is both reassuring and unnerving to know that the Committee on Diagnostic Error in Health Care, which produced the Institute of Medicine’s recent report on diagnostic accuracy1, first set out to produce a report on diagnostic error in medicine, but instead published a 315-page manifesto calling for the overhaul of the diagnostic process in healthcare. The committee, which included one prominent academic radiologist, Hedvig Hricak, MD, addressed the cultural, cognitive and institutional challenges in diagnosing disease, laying out eight recommendations for sweeping change.
The report is exhaustive: In its attempt to outline the complexities and pitfalls of the diagnostic process, the committee appeared to be thorough and conscientious. The section that dealt with the characteristics and physical environment of the diagnostic process—three concentric circles representing patients, diagnosticians (including radiologists and pathologists) and healthcare professionals—seemed very much the ideal to this outside observer.
I have seen a well-oiled diagnostic machine at work in a first-class urban hospital in the case of extreme disease. In most outpatient settings in which routine healthcare is initiated, however, the diagnostic environment described is a fiction. There is no coordination, orchestration or education. Hence, the committee’s urgent call for change.
While the report’s density and willingness to take on difficult concepts—such as differential diagnoses and probabilistic (Bayesian) reasoning—suggest it may not receive the attention that prior reports in this series have, it did include some numbers and issues that should make healthcare professionals and patients alike take notice. The committee concluded that most people will experience at least one diagnostic error in their lifetime; diagnostic error contributes to 10% of patient deaths; and between 6% and 17% of hospital adverse events are caused by diagnostic error.
Longstanding diagnostic shortcomings also see the light of day. Radiologists often complain about the paucity of clinical context received with an imaging order. Citing a 2014 paper by Obara et al,2 the committee points out that 59% of radiology orders do not include mention of important non-oncological conditions (e.g. Crohn’s disease, HIV and diabetes); and 8% fail to mention the presence of cancer where it exists.
The committee suggests that the clinical context may be thin because there has been no bedside evaluation, writing: “Verghese3 and colleagues noted that these methods were once the primary tools for diagnosis and clinical evaluation, but ‘the recent explosion of imaging and laboratory testing has inverted the diagnostic paradigm. [Clinicians] often bypass the bedside evaluation for immediate testing.’”
Patients first
The committee emphasizes that its new definition of diagnostic error makes patients central to the solution (and a critical partner in connecting the diagnostic dots): “Failure to a) establish an accurate and timely explanation of a patient’s health problems, or b) communicate that explanation to the patient.”
In fact, the first of the eight goals articulated in the report is to facilitate effective teamwork in the diagnostic process among professionals, patients and their families.
The second goal is to enhance professional education training in the diagnostic process, particularly instruction in generating differential diagnoses. Radiologists seeking support should check out gamuts.net developed by Charles Kahn, MD, PhD (see Radlex, page 10).
The third, fourth, fifth and sixth goals address health IT issues, systems and culture to support continuous quality improvement and fixes for our dysfunctional medical malpractice system. Goal seven recommends that a payment and care delivery system be designed that supports the diagnostic process. Any ideas? The final goal if adopted would provide dedicated funding for research on the diagnostic process and diagnostic errors.
To err at the outset of a health care episode is to expose the patient to unnecessary morbidity (possible mortality) and ensure waste. Read the report, be a part of the solution and if you can accomplish just one goal, let it be the first one. Engaging patients in their own healthcare is the solution that requires the least amount of resources to accomplish, but has the potential for the most immediate results.
References
- National Academies of Sciences, Engineering, Medicine. Improving diagnosis in health care. Board on Health Care Services. Institute of Medicine. Washington DC: The National Academies Press. Accessed October 28, 2015
- Obara PM, Sevenster A, Travis Y, Qian C, Chang PJ. Evaluating the referring physician’s clinical history and indication as a means for communicating chronic conditions that are pertinent at the point of radiologic interpretation. J Dig Imag. 2015;28:272-282.
- Verghese A. Culture shock—patient as icon, icon as patient. N Eng J Med. 2008. 359:2748-2751.
Vice President, Executive Editor, Radiology Business
Cheryl began her career in journalism when Wite-Out was a relatively new technology. During the past 16 years, she has covered radiology and followed developments in healthcare policy. She holds a BA in History from the University of Delaware and likes nothing better than a good story, well told.