By Evan Falchuk

The Journal of the American Medical Association just published an important Commentary (abstract here, full text is subscription-only) on the striking lack of attention being paid to diagnostic error:

Despite their major public health implications, diagnostic errors have received relateively little public or scientific attention, including from the patient safety community. . . In the Institute of Medicine’s Too Err is Human Report, diagnostic errors were mentioned only twice, compared with 70 mentions for medication errors. . . None of the 20 evidence-based Patient Safety Indicators established by the Agency for Healthcare Research and Quality (AHRQ) or the 30 safe practices recommended by the National Quality Forum specifically mention failure to diagnose. . . . A 2003 report of 93 AHRQ-funded patient-safety projects found only 1 focued on misdiagnosis.

There’s a reason for this.  Health care quality is conventionally thought of as bringing concepts of high-quality manufacturing processes to medicine.  Just as there is a right way and a wrong way to attach a door to a car, there also is a right way and a wrong way to treat a patient.  If we standardize the process of treating patients, we can eliminate defects in medical care.    The drive for patient safety over the last decade has focused on finding and working on those areas of medical care that fit this model.   Treating patients — the process of care — most closely fits.

But the framework breaks down when you apply it to the really hard and important part of medicine:  deciding on the the patient’s diagnosis.

Clinical decision-making requires thought, judgment and flexibility, all of which are not amenable to standardization.  Some doctors, like Jerome Groopman and Patrick Croskerry are speaking up about it, and along with others, like Dr. Mark Graber and Eta Berner, are publishing an increasingly extensive body of ground-breaking research on the subject.

Their basic conclusion is this:  the human brain is hard-wired to make decisions in certain ways.  We are good at deciding quickly, based on incomplete information.  It’s a very useful skill if, say, you need to decide quickly if the noise in the bushes is the wind or a tiger.   It’s can be very counterproductive if you have a complicated problem to solve, like trying to puzzle out a patient’s diagnosis.

In their thoroughly-researched and throughful 2008 paper noted above, Graber and Berner wrote, in describing the reasons for misdiagnosis:

Rarely, the reason for not knowing may be a lack of knowledge per se, such as seeing a patient with a disease the physician has never encountered before.  More commonly, cognitive errors reflect problems gathering data, such as failing to elicit complete and accurate information from the patient; failure to recognize the significance of data. . . or most commonly, failure to synthesize, or ‘put it all together.’  This typically includes a breakdown in clinical reasoning, including using faulty heuristics.

The scientific language of these studies tracks closely with the plain spoken stories people tell all the time about what it’s like to go to the doctor.  You have 15 minutes with your doctor, the doctor comes to a quick conclusion about what is wrong with you, he doesn’t seem terribly interested in that extra bit of information you think might be relevant, and you are given a prescription or referred to a specialist.  In these circumstances, we shouldn’t be surprised to read in the New England Journal of Medicine that 35% of doctors and 42% of patients have reported errors in their own care or that of a family member.

But it was surprising to see the JAMA commentary completely dismiss the research, saying that the focus on physician thought processes is a “false notion” that had “hindered development of error-reduction interventions.”  The commentary authors emphasize the need for more process- and protocol-oriented steps to address misdiagnosis, precisely the opposite of what the data suggest.  It is not clear from the commentary exactly why the doctors dismiss that research, but it is clear that this process-oriented way of thinking about misdiangosis is at the heart of the current health care quality movement.  It is a disturbing trend, and it is important that doctors who understand the difference make their voices heard.