The Persistent Problem of Diagnostic Error


December 01, 2015

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Hello and welcome. I am Dr George Lundberg, and this is At Large at Medscape.

As an anatomic pathologist who grew up in the autopsy room, I know that people who die have often been misdiagnosed during their lives.[1] As a forensic pathologist who has studied sudden, unexpected, and unattended death in adults, I know that a large number (as many as half, by my data[2]) of such deaths that would have been diagnosed as heart disease were found, on autopsy, to be related to many other causes but not heart disease. As a clinical pathologist who has supervised the performance of millions of lab tests, I know that physicians often order the wrong tests and subsequently misinterpret the results and fail to act appropriately.[3]

The Institute of Medicine (IOM) issued a landmark report called To Err Is Human in 1999[4] and a follow-up report called Crossing the Quality Chasm in 2001.[5] These reports together with Lucien Leape's bombshell 1994 JAMA article, "Error in Medicine,"[6] constitute the bulwarks of the patient safety movement but deal largely with errors in treatment.

In 2015, the IOM, now of the National Academies of Sciences, Engineering, and Medicine, has turned its attention to Improving Diagnosis in Healthcare.[7] Three members of the writing committee—Elizabeth McGlynn, Kathryn McDonald, and Urmimala Sarkar—spoke about this report on November 10, 2015, as The Lundberg Institute lecturers at the Commonwealth Club of California.

They described errors in diagnosis as a gigantic problem of largely undefined but vast scope, one that will require extensive and warranted changes.

The Committee enunciated eight goals:

  1. Employ more effective teamwork in the diagnostic process;

  2. Enhance healthcare professional education and training in the diagnostic process;

  3. Ensure that health information technologies support patients and healthcare professionals in the diagnostic process;

  4. Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice;

  5. Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance;

  6. Develop a reporting environment and medical liability system that facilitates improved diagnosis through learning from diagnostic errors and near misses;

  7. Design a payment and care delivery environment that supports the diagnostic process; and

  8. Provide dedicated funding for research on the diagnostic process and diagnostic errors.

That, dear readers, is asking nothing short of a revolution in American medical care delivery.

The committee concluded: "Improving the diagnostic process is not only possible, but it represents a moral, professional, and public health imperative."

The medical experts in diagnosis, pathologists and radiologists, now need to follow committee member Mike Laposata's long-standing example and create diagnostic management teams (DMTs). Such teams can greatly improve the quality of care and save tons of money that is now being wasted by failed diagnostic processes.

As a related and personalized issue, I have a small bandage on my right temple. There used to be a little lump there that you, via my videos, and I have watched grow. It ulcerated and would not heal. I made a clinical diagnosis. My dermatologist removed it. We will soon learn whether my clinical diagnosis was accurate and share in deciding what to do now.

That is my opinion. I am Dr George Lundberg, at large at Medscape.


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