This article was recently emailed to me by a loyal reader:
Doug, you might appreciate this article. Just one more example of how the small minded Lilliputians that surround us are destroying a once noble profession while wondering why it is not working out as they imagined it would.
He was talking about a piece in Medscape written by Lara C. Pullen, PhD called Missed and Erroneous Diagnoses Common in Primary Care Visits . The JAMA Internal Medicine concluded that “a large variety of common diseases are missed in the primary care setting and almost 80% of these errors stem from breakdowns in the patient–practitioner clinical encounter. Most errors also have the potential to cause moderate to severe harm”.
The most commonly missed diagnoses were:
- pneumonia (6.7%)
- decompensated congestive heart failure (5.7%)
- acute renal failure (5.3%)
- primary cancer (5.3%)
The authors identified several process breakdowns that contributed to missed diagnoses:
- Process breakdowns involved the patient–practitioner clinical encounter (78.9%)
- stemmed from referrals (19.5%)
- patient-related factors (16.3%)
- follow-up and tracking diagnostic information (14.7%)
- performance and interpretation of diagnostic tests (13.7%)
Here are the conclusions from the Medscape article:
In interpreting their data, the authors propose that as physicians increasingly rely on technology and team-based care there may be a drop in basic clinical skills and related cognitive processes. Shortened office visits may also exacerbate this problem.
The authors go on to discuss possible solutions, acknowledging that any solution will have to recognize that medical diagnosis is difficult, messy, and imperfect. They suggest that a focus on taking medical histories, performing physical examinations, and ordering tests may help reduce diagnostic error. In addition, it may be helpful to encourage physicians to document a differential diagnosis at the initial visit.
Richard L. Faiola, MD, who tipped me off on this article, was amazed how it “confuses in its headline care rendered in a VA medical center with anything remotely related to the REAL world of PRIMARY CARE but does correctly suggest there just might be something to REAL doctors practicing REAL medicine. What a concept!!!”Tweet