Martin is a healthy 38-year-old. One day he cuts his workout short because he feels winded. The same thing happens over the next several days, and he develops a fever. At an urgent care office, Martin is diagnosed with viral bronchitis and given an inhaler. He gets worse and goes back a few days later. This time he receives a chest x-ray and a new diagnosis: pneumonia. He's prescribed antibiotics. On a third trip, he receives different antibiotics. Six weeks after that first disrupted workout, Martin goes to the emergency room. There, an astute clinician asks Martin if he spends much time outdoors. Actually, he'd been on a weeklong hiking and fishing trip before getting sick. Further testing reveals an uncommon fungal infection of the lungs. The diagnosis comes just in time. These kinds of cases are more common than you might think. I know because I'm an internal medicine doctor. We miss diagnoses all the time. Last year, researchers at Johns Hopkins made the bold claim that medical errors are the third leading cause of death in the United States, behind heart disease and cancer. While some critics thought this estimate was inflated, health professionals tend to agree on one point: Medical errors are more common than they should be. The medical community has become more attentive to errors during the past two decades. Electronic record systems can flag medication interactions. Before any surgical procedure, the surgeon marks his or her initials where the scalpel will go. Yet a silent epidemic of a particular type of medical screwup persists: the diagnostic error. Ways to Slip Up During a typical doctor's office visit, you probably describe your symptoms, get examined, and maybe go for tests. The doctor must then decode this information—which essentially amounts to a puzzle—and consolidate it into a solution. The conclusion of the process is the diagnosis: a label, often a loose working theory (or set of theories) describing what's bothering you. Sometimes this process goes wrong. Diagnostic errors fall into three main types: Misdiagnosis Your physician applies the wrong label or name to your symptoms. Delayed diagnosis Your physician had the information to promptly label your problem but didn't act until your symptoms were unmistakable. Missed diagnosis Your physician completely neglected to consider a certain condition that explained your symptoms. Diagnostic errors frequently fly under the radar. Take Martin's case. Was it even possible for the doctor at the urgent care facility to diagnose Martin with an uncommon infection when the initial symptoms were so consistent with those of a run-of- the-mill cold? How about the second physician? The third? Perhaps Martin should bear part of the responsibility since he didn't disclose the key clue—the wilderness trip—earlier. Many cases aren't cut-and-dried. The Cost of Inaccuracy Proper diagnosis is arguably the most critical element of patient care. A flawed assumption about your condition at the outset will inform all the treatment that follows. Beyond the obvious—your life could be at stake—are other important consequences. Flawed evaluations can breed skepticism in health care. A botched diagnosis could sabotage your trust in your provider and any future doctors you might consult. And, of course, if you're sent down the wrong path, you'll take a financial hit. Are You at Risk? Studies suggest that diagnostic errors occur in 10 to 15 percent of cases, whether in clinics, emergency departments, or hospitals. These rates haven't budged despite impressive advances in medical technology, so don't think fancy genetic testing or pricey MRIs offer infallible protection against a bad diagnosis. What's more, don't assume that only rare diseases are missed; in fact, the opposite is more likely. Most errors happen with patients who have relatively common conditions. How Mistakes Happen Doctors are human. They get tired, hungry, depressed, confused, and annoyed. They can be rushed, working in chaotic settings. They forget things. Some things they never learned. Some doctors are overconfident; others are too tentative. It helps to understand how a diagnostician's mind works. When you describe a problem, your doctor relies on two types of reasoning. First, there's a fast-acting circuit that leans on snap judgments. A second process is more deliberate and analytical. But both circuits can short out. The "snap judgment" system is especially vulnerable to bias. The second, more deliberate system seems more fool-proof, but overthinking your case can also send you both in the wrong direction. How Can You Avoid Diagnostic Error? You can't change a doctor's mood, memory, or fatigue level, and you can't know whether he or she is keeping up on the latest research. But you can keep yourself safe in other ways. Read on. If you're confrontational or antagonistic, you're not helping. Research shows that doctors make more mistakes when they're dealing with "difficult" patients. 1. Find an attentive doctor Doctors tend to be influenced by past test results and labels attached to an illness. It's called "diagnostic momentum," and it can sometimes close a doctor's mind about your care. Say you have chest pain—one of the 7 pains you should never ignore—and worry that it's a heart problem. If you also have an anxiety disorder, that label could make your doctor think the pain is all in your head, particularly if other providers you've seen have drawn the same conclusion. If you sense that your doctor has strong preconceptions about you, seek another opinion. In my experience, keen diagnosticians are curious, patient, willing to carefully examine their patients, and have a healthy dose of skepticism and humility. You should also seek out the most experienced provider you can find, possibly at an academic or specialty medical center. If your doctor has a "not my area, not my problem" approach, go elsewhere. 2. Prepare for your visits Jot down notes and questions before your appointment. Even cool-and-collected types forget things. There is a misconception that physicians are annoyed by patients who google their symptoms and self-diagnose. For the most part, they don't mind; it's all in how you frame your questions. Don't say: "Hey, I found this disease online, and I'm certain I have it. So please send me for blood work and a CT scan." Instead, gently inquire about what you've read online; your doctor should consider it. In addition, keep a list of meds you take and save the results of your cardiac stress tests and scans (CT and MRI) and most blood work. Use a mobile or cloud-based app or even a simple Word document or spreadsheet. 3. Explain your symptoms in a clear, logical way Clinicians are trained to zero in on the first symptom you mention. If you have multiple problems that you think might be related, say so up front. Then give a chronological account of what you're experiencing, referring to a calendar if possible. Doctors view the passing of time itself as a diagnostic clue. Use similes to describe symptoms: "My stomach feels like something is chewing at it," for example. Otherwise, doctors may try to translate your complaints into their own parlance, at least mentally, in an example of "ascertainment bias," or looking for what they expect to find. They just want to categorize your symptoms in order to whittle down the possibilities. Don't settle for medicalese; keep at it until you're both on the same wavelength. 4. Ask what else it could be A "diagnostic timeout" is a powerful way to avoid errors. In studies, doctors admit that sometimes the diagnosis simply never crossed their mind. The simple question "What else could this be?" may help your doctor out of a rut by avoiding two common traps. "Premature closure" is when a case is seen as open-and-shut and the doctor essentially turns off his or her brain. "Confirmation bias" refers to seeking only the information that bolsters the current theory and ignoring the rest. Experts agree that being open about uncertainty is key. If you get the sense that ego is preventing your doctor from expressing doubt, find a new provider. 5. Know which tests you're getting and why A blind stab at your case can be just as dangerous as an utterly incorrect diagnosis. Your doctor should be able to explain why a certain test is needed, how influential the results will be, and what your alternatives are. In other words, the doctor should know the possibilities and also articulate the most efficient way to arrive at a diagnosis. 6. Never assume that no news is good news Here's a shocker: One significant cause of diagnostic error is failure to follow up on abnormal test results. As a patient, you're entitled to timely disclosure of test results. If you spot an abnormality in blood work or on an x-ray report that doesn't seem to faze your doctor, speak up. 7. Be respectful If you're confrontational or antagonistic, you're not helping. Research shows that docs make more mistakes when they're dealing with "difficult" patients. Try to stay calm and cordial. It's okay to express emotions and frustrations, and there are times when you absolutely need to advocate for yourself. But realize that negative vibes will muddy your doctor's thought processes. 8. Remember that you're in the driver's seat Since the dawn of medicine, the patient has literally sat in the center of the diagnostic process. If you feel you aren't being heard, seek a second opinion. Source
