Is Misdiagnosis Inevitable?

Leigh Page

Disclosures

March 28, 2016

In This Article

System-Based Barriers Cause Misdiagnoses

Besides the reasoning process, there are many issues having to do with the system of care that can cause diagnostic errors. Basically, these involve issues with patients and diagnostic tests.

It's clear that patients play a key role in misdiagnoses. A 2013 study[9] found that the biggest source of process breakdowns that cause diagnostic errors had to do with a faulty patient/practitioner encounter. For example, patients might fail to come in for a follow-up visit with their regular physician or with a specialist that would help narrow the diagnosis.

Dr Graber thinks physicians should make a greater effort to make patients "partners" in the diagnostic process, and this is a recommendation of the IOM report. Even before doctors have formulated a final diagnosis, Dr Graber says, they should work with patients to sort through possible diagnoses. Many doctors don't want to let on to patients that they are unsure of the diagnosis, but "if you admit you're not sure yet and give them some possibilities, the patient can help you narrow them down," he says.

He also thinks physicians should have the right amount of time to evaluate patients. "Diagnosis takes time," Dr Graber says. "It takes time to get a complete history, to do a meaningful physical examination, and to get to know the patient."

According to a 2015 Medscape survey,[15] doctors typically spend about 13-16 minutes with a patient. But that may not be enough for a challenging diagnosis. The IOM report says payments should be adequate for "performing a thorough clinical history, interview, and physical exam," but it notes that the payment system discourages this. Under Medicare, the report says, doctors who have to spend 20 minutes instead of 15 minutes for a level 3 visit receive 25% less revenue per hour.

To deal with these problems, the IOM report says payers should improve payments for cognitive activities, such as "a thorough clinical history, interview, and physical exam, or decision-making in the diagnostic process."

In the realm of diagnostic testing, misdiagnoses can occur when the tests are not performed, the interpretation of tests is faulty, or abnormal results are missed, the IOM report says.

Physicians may fail to order a test because they're confident that they already have the diagnosis. A 2013 study[16] found that internists who indicated that they were highly confident of their diagnosis but were wrong did not order more tests.

Physicians may be discouraged from ordering more tests by insurance company policies, such as requiring precertification for an imaging exam. For example, a pilot program run by UnitedHealthcare in Florida requires doctors to submit a "prenotification" electronically and get a confirmation back before ordering any of nearly 80 different lab tests. According to a news report,[17] several medical societies in Florida have objected to this program, saying that it requires extensive data entry.

The movement to cut down on possibly unnecessary testing may also discourage physicians from ordering the tests they need. In the Choosing Wisely campaign, for example, some specialty societies have identified imaging tests as subject to overuse. The campaign has been criticized for attempting to replace a physician's judgment with a rigid set of rules, when in fact there are many exceptions.

Even when tests are ordered, some physicians may fail to follow up on abnormal results. In a 2014 study[18] detected 1048 cases of delayed or missed follow-up of abnormal findings of diagnostic tests, including 47 high-grade cancers.

Failure to follow up on test results may be caused by poor communication between the treating physician and the physician interpreting the results. The IOM report advises that Medicare should reimburse physicians for the "time spent by pathologists and radiologists in advising treating physicians on testing for specific patients."

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