Most people will experience at least one medical diagnostic error — an inaccurate or delayed diagnosis — in their lifetime, sometimes with devastating consequences.
That’s the top-line takeaway from a new report, “Improving Diagnosis in Health Care,” by the Institute of Medicine of the National Academies of Sciences, Engineering and Medicine. The Sept. 22 news release announcing publication of the report had the headline, “Urgent change needed to improve diagnosis in health care or diagnostic errors will likely worsen.”
While that’s a long-overdue acknowledgement that adds to the growing evidence of a dysfunctional system, if the Institute of Medicine was honest, it would also admit the finding represents a keen grasp of what should be the obvious.
“Despite the pervasiveness of diagnostic error and the risk for patient harm, they have been largely unappreciated within the quality safety movement in health care,” National Academy of Medicine President Victor Dzau said at a news briefing on the report, “and this cannot and must not continue.”
It’s been said an alcoholic first has to admit to himself he has a drinking problem before the problem can be addressed, but that’s just the first step in a lengthy, 12-step program. In similar fashion, the institute’s report is a much-needed first step in addressing the widespread problem of misdiagnoses that, as with alcoholism, risks relapse in the absence of ongoing monitoring.
The committee that conducted the study and wrote the report concedes efforts to improve diagnosis and reduce diagnostic errors have been quite limited. The report, Dzau said, “is a serious wake-up call that we still have a long way to go.”
If past is prologue, the health care system’s answer to that wake-up call will be to ignore the alarm and roll over and go back to sleep.
It’s true that improving diagnosis is a complex challenge, in no small part because making a diagnosis is a diffused and inherently inexact process that more often than not occurs over time and across multiple health care settings. “Diagnosis is a collective effort that often involves a team of health care professionals, from primary care physicians to nurses to pathologists and radiologists,” rather than something discerned by a single physician in a single patient visit, said John Ball, executive vice president emeritus of the American College of Physicians and chairman of the committee that produced the report.
While there’s some truth to that, it also sounds like an effort to diffuse the blame for inaccurate or delayed diagnoses — not unlike in the “Family Circus” comic strip, where Mom asks who’s responsible for the broken vase, and all the young children in unison innocently insist: “Not me!”
Unlike a broken vase, which can be replaced, wrong or delayed diagnoses can have tragic consequences. In the worst-case scenarios, a belated diagnosis of cancer or a heart problem can mean the difference between life and death, or in the case of a stroke, permanent disability.
Data on diagnostic errors are sparse, few reliable measures exist and errors are often found in retrospect, according to the committee, whose prescription for triaging the problem calls for more effective teamwork among health care professionals, patients and patients’ families; improved training; more emphasis on identifying and learning from diagnostic errors and what it called “near misses” in clinical practice; and a payment and care-delivery environment that supports the diagnostic process.
Those are all well and good as far as they go, but “Improving Diagnosis” goes seriously astray when it recommends tort reform (also known as medical-malpractice reform), suggesting that would allow transparency in the reporting of errors. That’s misguided and self-serving, as it suggests there isn’t reporting of errors now due to a fear of litigation.
Does the institute really think that would change if the threat of malpractice lawsuits is diminished? There are other, more contemporaneous constraints to the reporting of errors — namely, the fear of professional scorn, exclusion and penalty.
The problem is that there’s no real institutional accountability, and there’s far too little reporting of diagnosis error, because health care practitioners will always find reasons to cover up errors.
In short, then: Physician, heal thyself.
Dr. Lawrence B. Schlachter, a board-certified neurosurgeon and attorney in Atlanta, is the author of the forthcoming book, “Malpractice: A Board-Certified Neurosurgeon Reveals How the American Health Care System Harms Patients and Protects Dangerous Doctors.”