May, 7, 2013 - Until it happened to him, Itzhak
Brook, a pediatric infectious disease specialist at Georgetown
University School of Medicine, didn't think much about the problem of
misdiagnosis. That was before doctors at a Maryland hospital repeatedly
told Brook his throat pain was the result of acid reflux, not cancer.
The correct diagnosis was made by an astute
resident who found the tumor - the size of a peach pit - using a simple
procedure that the experienced head and neck surgeons who regularly
examined Brook never tried.
Because the cancer had grown undetected for seven
months, Brook was forced to undergo surgery to remove his voice box, a
procedure that has left him speaking in a whisper. He believes that
might not have been necessary had the cancer been found earlier.
"I consider myself lucky to be alive," said Brook,
now 72, of
the 2006 ordeal,
which he described at a
international conference on diagnostic mistakes held in
Baltimore. A physician for 40 years, Brook said he was "really shocked"
by his misdiagnosis.
But patient safety experts say Brook's experience
is far from rare. Diagnoses that are missed, incorrect or delayed are
believed to affect
10 to 20 percent
of cases, far exceeding drug errors and surgery on the wrong patient or
body part, both of which have received considerably more attention.
Recent studies underscore the extent and potential
impact of such errors.
funded by the federal Agency for Healthcare Research and Quality found
that 28 percent of 583 diagnostic mistakes reported anonymously by
doctors were life-threatening or had resulted in death or permanent
a new study
of 190 errors at a VA hospital system in Texas found that many errors
involved common diseases such as pneumonia and urinary tract infections;
87 percent had the potential for "considerable to severe harm" including
Misdiagnosis "happens all the time," said
Newman-Toker, who studies diagnostic errors and helped
organize the recent international conference.
"This is an enormous problem, the hidden part of
the iceberg of medical errors that dwarfs" other kinds of mistakes, said
Newman-Toker, an associate professor of neurology and otolaryngology at
the Johns Hopkins School of Medicine.
Studies repeatedly have found that diagnostic
errors, which are more common in primary-care settings, typically result
from flawed ways of thinking, sometimes coupled with negligence, and not
because a disease is rare or exotic.
The problem is not new: In 1991, the
Practice Study found that misdiagnosis accounted for 14
percent of adverse events and that 75 percent of these errors involved
negligence, such as a failure by doctors to follow up on test results.
Despite their prevalence and impact, such mistakes
have been largely ignored, Newman-Toker and others say. They were
mentioned only twice in the
Medicine's landmark 1999 report on medical errors, an
omission some patient safety experts attribute to difficulties measuring
such mistakes, the lack of obvious solutions and generalized resistance
to addressing the problem.
"You need data to start doing anything," said
Mark L. Graber,
founding president of the Society to Improve Diagnosis in Medicine and a
leading errors researcher. Despite dozens of quality measures, Graber
said, he is unaware of "a single hospital in this country trying to
count diagnostic errors."
In the past few years, a confluence of factors has
elevated the long-overlooked issue. In his 2007 bestseller, "How
Doctors Think," Boston hematologist-oncologist Jerome
Groopman vividly deconstructed the flawed thought processes that
underlie many diagnostic errors, including several he made during his
More recently, an influential cadre of medical
leaders has been pushing for greater attention to the problem. They cite
concerns about the growing complexity of medicine and increasing
fragmentation of the health-care system, as well as relentless time
pressures squeezing doctors and the overuse of expensive, high-tech
tests that have supplanted traditional hands-on skills of physical
Publicity about the death last year of 12-year-old
sent home from an emergency room in New York after doctors missed the
raging systemic infection that quickly killed him, have put a human face
on the problem. At the same time, new digital databases such as
promise to boost doctors' accuracy, although their usefulness remains a
matter of debate.
"One of the reasons it's time to begin looking at
it is that so many of the quality measures we use now assume that the
diagnosis is the right one in the first place," said Christine Cassel. A
member of the panel that wrote the 1999 IOM report, she is now president
and chief executive officer of the American Board of Internal Medicine.
But what if it's not?
In a much-cited essay, Robert Wachter, associate
chair of the Department of Medicine at the University of California at
San Francisco, wrote that a hospital could earn "performance incentives
for giving all of its patients diagnosed with heart failure, pneumonia
and heart attack the correct, evidence-based and prompt care -- even if
every one of the diagnoses was wrong."
Discovered Late -- Or Never
Unlike drug errors and wrong-site surgery --
mistakes that patient safety experts consider to be "low-hanging fruit"
amenable to solutions such as color-coded labels and preoperative
timeouts by the surgical team -- there is no easy or obvious fix for
diagnostic errors. Many are complex and multifaceted, and may not be
discovered for years if ever, said Graber, a senior fellow at RTI
International, a research firm based in Research Triangle Park, N.C.
"There is probably nothing more cognitively
complicated" than a diagnosis, he said, "and the fact that we get it
right as often as we do is amazing."
But doctors often don't know when they've gotten it
wrong. Some patients affected by misdiagnosis simply find a new doctor.
Unless the mistake results in a lawsuit, the original physician is
unlikely to learn that he blew it -- particularly if the discovery is
delayed. While diagnostic errors are a leading cause of malpractice
litigation, the vast majority do not result in legal action.
Some environments are more susceptible to error
than others. Graber calls the emergency room "a petri dish" for
diagnostic mistakes: The doctor doesn't know the patient, the patient
doesn't trust the doctor, and time pressures and frequent interruptions
are the rule.
Misdiagnosis is not limited to hospitals; a recent
commentary on the Texas VA study by Newman-Toker and Martin Makary
estimates that "with more than half a billion primary care visits
annually in the United States . . . at least 500,000 missed diagnostic
opportunities occur each year at U.S. primary care visits, most
resulting in considerable harm."
There is another reason such mistakes have been
long ignored: They are regarded as an unusually personal failure in a
profession where diagnostic acumen is considered the gold standard.
"This really gets to who we are as clinicians,"
said internist Robert Trowbridge, who directs the medicine clerkship
program for Tufts University medical students at Maine Medical Center in
"Overconfidence in our abilities is a major part of
the problem," said Graber, who believes doctors have gotten a pass for
too long when it comes to diagnostic accuracy. "Physicians don't know
how error-prone they are."
Many, he noted, wrongly believe that the problem is
"the other guy" and that they don't make mistakes. A
of more than 6,000 physicians found that 96 percent felt that diagnostic
errors are preventable; nearly half said they encountered them at least
once a month.
In the Texas VA study, more than 80 percent of
differential diagnosis, in which a doctor not only declares
what he believes is ailing the patient but also lists other potential
causes of the problem based on symptoms, test results and a physical
"A differential helps people to cognitively focus,"
said Hardeep Singh, director of the Houston VA Patient Safety Center of
Inquiry. Failure to ask "What else could this be?" can cause premature
fixation on the incorrect diagnosis, said Singh, the study's lead
At Maine Medical Center, Trowbridge spearheaded a
pilot program launched in 2010 to persuade doctors to anonymously report
diagnostic errors, which would then undergo comprehensive analysis. He
said he had to "hound" his colleagues to report mistakes. During the
first six months, 36 errors that would otherwise have gone unreported
were identified; most were deemed to have caused moderate to severe
Trowbridge said the program has changed how he
practices. "I'm much more reflective, much more attuned to the errors
I'm prone to make. I work with checklists more."
It Wasn't Fibromyalgia
While second opinions are one strategy believed to
reduce misdiagnosis, the original error may be the basis of a cascade of
For nearly three years, beginning in February 2008,
financial executive Karen Holliman logged more than 50 visits with
various doctors in Durham, N.C., trying to get help for the increasingly
severe fatigue that had plagued her for several years as well as back
pain so excruciating that she wound up in a wheelchair.
Doctors variously told her she had fibromyalgia,
chronic fatigue syndrome or a psychiatric problem. The real reason for
her symptoms was metastatic breast cancer, which had riddled her spine,
fracturing her back. Signs of cancer had been found on an MRI scan
performed in February 2008. But a bone scan performed a few weeks later
did not indicate cancer; her internist told her she did not have cancer,
and doctors repeatedly failed to investigate the discrepancy.
To make matters worse, Holliman was taking hormone
replacement pills prescribed by her internist to combat hot flashes; the
drug fed her breast cancer.
"I'm terminal," she said. In December 2010, when
she was told she had Stage IV breast cancer, an oncologist estimated her
life expectancy at about three years. "I could have been diagnosed in
2008," she said, adding that she believes timely diagnosis and treatment
might have extended her life expectancy to 10 years.
Holliman has regrets: that she never got a second
opinion from an internist or orthopedist, that she didn't question the
radiologists who performed her scans and that she failed to obtain her
medical records earlier.
During meetings last year attended by her family,
including a relative who is a prominent physician, as well as by her
doctors and the hospital system for which they worked, Holliman said, a
hospital lawyer called her case "a series of unfortunate events" but
denied that the hospital was liable for the delayed diagnosis.
"I spent a lot of time being angry," said Holliman,
who is 52. She said she has not filed a malpractice suit because she was
advised she was unlikely to win. "Now I'm just trying to live a really
great life in the time I have left."