Nearly 1 in 6 Docs Say They Make Diagnostic Errors Every Day

Marcia Frellick

September 10, 2019

One in six physicians estimated in a Medscape poll that they make diagnostic errors every day.

That number varied by specialty. Pediatricians were less likely to say they made diagnostic errors every day (11%) and emergency medicine (EM) doctors were more likely, at 26%. In between were physicians in family medicine (18%), general practice (22%), and internal medicine (15%).

Nurses, advanced practice registered nurses, and physician assistants (PAs) answered similarly: in all three categories, 17% said they estimated they made diagnostic errors daily.

Poll questions, posted June 26, were posed after Medscape reported results from a study in the Journal of General Internal Medicine that suggested that physicians tend to underestimate how often they make diagnostic errors.

Responders included 633 physicians and 118 nurse practitioners (NPs)/PAs, for a total of 751.

Researchers at the Johns Hopkins University School of Medicine in Baltimore, Maryland, conducted a survey of physicians at nine Connecticut internal medicine training programs to assess thoughts about diagnostic uncertainty and error. 

Most believed diagnostic errors to be uncommon (once a month or less), despite half of them reporting that they felt diagnostic uncertainty every day. Previously published figures estimate that diagnostic errors occur in 10% to 15% of all patient encounters.

A registered nurse wrote in the Medscape poll comments that it's important to make a distinction between incorrect diagnoses and uncertainty. "The latter is part of the basis for a referral to a specialist," he noted.

Poll results indicated that NPs and PAs in the poll reported slightly higher rates of daily diagnostic uncertainty than did physicians.

Table. Frequency of Diagnostic Uncertainty by Provider

Frequency % Physicians % NPs/PAs
Every day 52 64
About once a week 20 21
Several times a month 13  9
Once a month 14  5
Never  0  0

 

Uncertainty rates were similar for male and female physicians.

Reasons for Errors

Physicians and NPs/PAs agreed on the top three reasons diagnostic errors occur. One was "lack of feedback on diagnostic accuracy" (38% of physicians and 44% of NPs/PAs listed that as a top factor). Another was time constraints, listed by 37% of physicians and 47% of NPs and PAs. Rounding out the top three was "a culture that discourages disclosure or errors" (27% physicians, 33% NPs/PAs).

Emergency medicine physicians were more likely than physicians in general (76% vs 52%) and NPs/PAs (64%) to say they experienced diagnostic uncertainty daily.

An emergency medicine physician who commented on the poll offered an explanation for uncertainty in his specialty: "I dare say we in EM cannot give a definitive diagnosis in the majority of undifferentiated presentations we see," he said.

"Our primary objective is to perform a 'medical screening exam' to rule out to a reasonable degree of certainty that an Emergency Medical Condition is not the cause of the patient's acute chest pain, abdominal pain, headache, etc. We focus on making the safest disposition through evidence-based risk stratification processes. It is a system that works fairly well sorting the emergent from the non-urgent," he said. "We strive to be honest in that we often don't know the definitive cause of the low risk chest pain, headache, abdominal pain, etc. Often our most important intervention is simply reassurance that it is safe to follow up with the specialist for further testing — we are dispositionalists more often than we are diagnosticians."

Asked at what point they experienced diagnostic uncertainty, the greatest percentages of providers (70% of physicians and 76% of NPs/PAs) answered that it was when making the actual diagnosis. The second most frequent time for uncertainty was when deciding what tests to order (34% for physicians and 50% for NPs/PAs).

An internist said one cause of uncertainty in diagnosis was not listed as an option in the poll — "the inherent nature of biological systems." Not all symptoms or conditions can be diagnosed, at least in a timely manner, he said.

"We are not 'omnipotent,' " he wrote. "We do not understand in totality human physiology/pathology. Just because a diagnostic 'label' cannot be applied to a patient within a certain time, or that a reasonable diagnosis was applied that turns out to be 'incorrect,' does not mean an 'error' occurred."

A veterinarian who responded to the poll said that artificial intelligence (AI) may one day bridge the gaps in diagnosis for healthcare providers of all kinds.

"There are so many variables and possibilities I'm convinced, even for seasoned practitioners, our salvation will be A.I. and we will collaborate with our computerized 'partners,' " he said.

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