Common Diagnoses Errors in Primary Care and How to Fix Them
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!!!”
Did you catch the part were they suggest we focus on taking medical histories and performing physical examinations? I have to assume they mean a more comprehensive history and exam since we always do this anyway — remember, Medicare REQUIRES that ONLY the physician/provider can enter the CC and take the HPI. I would like for someone to tell me how I will have time to take and document such a history and exam for every patient who presents with a cough. If I had the time, and assuming my patients would tolerate these onerous visits for what should be a quick H&P and maybe a prescription, how could I ethically justify the resulting 99215 code/charge even if the documentation supported it? I see the authors are also suggesting that I order more tests, as well. Who is going to pay for all of this? We have PhD’s telling MD’s how to diagnose illness without considering the consequences of those recommendations, and we have editors at JAMA who are so hard up for news that they will publish anything. And they wonder why only a very small percentage of active physicians belong to the AMA.
Actually, a 93.3% successful diagnosis of pneumonia is quite good in my experience. The sensitivity and specificity of chest auscultation for pneumonia must be significantly lower than this, and the history can be notoriously unreliable. Of course, 6.7% failure sounds worse than 93.3% success.