Eric Turkewitz

Misdiagnosis Occurs In 15 To 20 Percent Of All Cases

Cross-posted from New York Personal Injury Law Blog

Misdiagnosis occurs in 15 to 20 percent of all cases, according to a new book out by Dr. Jerome Groopman called "How Doctors Think."

In an op-ed in today's Boston Globe (The Mistakes Doctors Make) based on the book, Dr. Groopman writes:

Why do we as physicians miss the correct diagnosis? It turns out that the mistakes are rarely due to technical factors, like the laboratory mixing up the blood specimen of one patient and reporting another's result. Nor is misdiagnosis usually due to a doctor's lack of knowledge about what later is found to be the underlying disease.

Rather, most errors in diagnosis arise because of mistakes in thinking.

In the piece, he deconstructs how a tumor was missed for years in a woman who had just given birth.

The book is reviewed at this link to Time. The Time lead is for an overlooked tumor in an 8-year old. According to the review,

[Groopman] learned that about 80% of medical mistakes are the result of predictable mental traps, or cognitive errors, that bedevil all human beings. Only 20% are due to technical mishaps--mixed-up test results or hard-to-decipher handwriting--that typically loom larger in patients' minds and on television shows.

The result of Groopman's journey is How Doctors Think (Houghton Mifflin; 307 pages), an engagingly written book that is must reading for every physician who cares for patients and every patient who wishes to get the best care. Groopman says patients can prompt broader, sharper and less prejudiced thinking by asking doctors open-ended questions and learning to identify some of their common thinking mistakes.

While some have a knee-jerk reaction to the attorneys who initiate suit on behalf of patients injured by malpractice, it's nice to know that some doctors are thinking about the actual problem. Because shooting the messenger, a time-honored way of changing the subject, is a lousy way of fixing a problem.

(Globe op-ed via David Williams at Health Business Blog)

Addendum 3/21/07 -- Dr. Groopman on The Colbert Report.

Eric Turkewitz: Author Bio | Other Posts
Posted at 12:33 PM, Mar 22, 2007 in
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What it proves actually that doctora are just human ,medical sciences have miles to go even after correcting all technical errors and the never ending quest for perfection by suing is at best futile.

Posted by: Anirban | March 22, 2007 4:20 PM

Win a few, lose a few, eh, Anirban? If you got 'imperfect' care that jeopardized your life, would you feel the same - especially if it was a preventable error and about a physical circumstance you had warned your physician might arise?

At what point is a mistake egregious enough for you to grant that a claimant has a right to object to how they were cared for? You might want to consider Prof. Silver's article The Poor State of Health Care Quality in the US
He argues persuasively that if fields such as architecture and rocket science have incentives for professional self-monitoring and improvement which are missing in medicine.

Here's a for-instance - the courts recognize the authority of so-called 'experts' to state opinions about the predictability of particular outcomes, but there is little (if any) precedent for taking into account a patient's experience-based expertise on their own body and it's particular quirks and history - Doesn't matter if their history is documented in medical records readily accessible to the professional who provides care, even if that history was referred to by the patient ahead of a doctor being too 'human' in disregarding that information when considering a current situation.

I am cognizant that it is the very definition of 'non-professional' to give a personal example, but to use feminist language that was old even before my time, 'The personal is political.' I have a mechanical heart valve that requires me to take blood thinning medication to deter my body from trying to cover up what it doesn't recognize and can't eject. If my body did it's natural job of covering the foreign entity with cells to try to make it recognizable, the smooth surface of the mechanical valve would throw material back into the bloodstream and cause emboli in the body, possibly in the brain. Of course, being anti-coagulated is contra-indicated for times of surgery when one needs to be able to mend quickly, and I've had my share of strokes when we've reversed anticoagulation for procedures. There are many risks I must take in stride. In addition to the myriad problems I've had with strokes, I've also clotted off the entire valve after a miscarriage, since post-delivery is a hyper-coagulative time (I'd love to describe congestive heart failure and ventricular fibrillation here - but maybe over coffee sometime, yes?) and hemorrhaged life-threatening amounts post-surgically so I have a LOT of knowledge about complications and their impact on my life. There's a good chance I have an odd clotting behavior of some kind that has not been diagnosed (and, believe me, we've tried to ascertain what that might be) on top of the 'normal' complications anti-coagulation inflict.

My medical records at this particular facility include a nose-bleed 45 days prior to the procedure I'm discussing which required an ER visit when my nose hadn't clotted in 5 hours, ultimately needing cauterization twice, and another 'minor' surgery ten months prior where post-surgical bruising was so severe that nerve damage was feared as a result. Both of these events were fully documented and available for electronic review should disclosure by a patient (as opposed to an 'expert') not seem sufficiently credible. But neither my exhaustive list of bleeding/clotting complications nor the medical record at that facility apparently provided sufficient information for her to choose to err on the side of caution, as they say, and keep me over one night for observation. My discharge immediately after the procedure was a done deal before I regained consciousness, and when I asked to speak with the surgeon about her decision (I was still woozy but both I and my family raised extensive objections), we were refused access to the surgeon to ask her reconsider.

Months later, when I asked why she'd made that judgment given all I'd told her about my history, she responded that I 'looked dry' when I was closed up. Yes, of course I looked dry at that point - I WAS dry then. The tricky 'wet' part, if you will, is after surgery when I need to go on both oral and injectable bloodthinners simultaneously to bring me back to a therapeutic level of anticoagulation as quickly as possible - which tends to be a process that is an inexact 'science' because so little is known about how physical chemistry variances can impact it. It's a process that I'd argue is dependent on too many factors medicine knows too little about to be left unmonitored for those prone to complications as my documented history shows I am.

I was discharged over my objections and bled out internally at home. My 'quest for perfection' had a 'part two' with the head of the trauma team refusing to adequately treat respiratory distress because he told my parents I was having an 'anxiety attack.' Now, of course, I'm no expert, but I've been told that 'anxiety' can't lead to respiratory arrest - common sense tells you that if anxiety got you to hyperventilate, the body would make you lose consciousness so it could resume a natural breathing state. I went into respiratory arrest because of abdominal compartment syndrome - my diaphragm could no longer move because there was too much blood pooled. Compartment syndrome had been diagnosed at least 24 hours BEFORE my arrest (more likely 48, but I don't have the record at my fingertips) and leads to death in 100% of patients who don't get treatment and nearly 3/4 of those who do.

I would have accepted a 'common sense' standard as opposed to 'perfection,' mind you. Medical error rate prove that doctors can be arrogant and hold their opinions in higher regard than the informed experience of his or her patient who will have to live or die as a consequence of the physicians action or inaction. It also demonstrates that our society has not asserted the same kind of pressure for achievable reliability as we do on other professions which require extensive training, skill development, and independent thinking (see above).

Posted by: Haley | April 8, 2007 9:35 AM

The patient has the most information about symptoms. Someone, even with no health knowledge, should question every health decision and act. That helps providers double check themselves and find their own mistakes. If a doctor refuses to listen or to use this information, the patient should complain to the doctor. If the doctor refuses to act, then change doctors. It is better to offend a doctor than to die or suffer.

The fear of litigation also causes health providers to cover up and to get unnecessarily defensive, instead of fully investigating, learning, and changing methods. This cover up causes an arrogance that interferes with continual improvement. Most smart doctors listen. For example, Sen. Specter had headaches. They would go away. He demanded a brain scan, and found his own tumor. He went to a government hospital. In private practice, the scan would have been done long before, and without his asking. This happened to be the best government has. In France, Lady Diana died as socialist emergecy people futzed around at the scene. In the US, a helicopter would have been there, taken her to a hospital in 5 minutes, and she would be alive.

All diagnostics have false positives and false negatives. The public has to decide how much to spend on finding the hidden tumor on 1 in 10,000 people versus on vaccinations that save countless people. These anecdotes muiltiplied across the nation would break the budget. In most cases, whatever is being missed goes away on its own.

Let's also discuss the across the board 75% false positive rate of medmal cases going to trial, and the thinking that imposes supernatural future forecasting on the public at the point of a gun by the lawyer. Those with unclean hands should not point fingers.

Posted by: Supremacy Claus | April 9, 2007 8:47 AM

Medical error rate prove that doctors can be arrogant and hold their opinions in higher regard than the informed experience of his or her patient who will have to live or die as a consequence of the physicians action or inaction. It also demonstrates that our society has not asserted the same kind of pressure for achievable reliability as we do on other professions which require extensive training, skill development, and independent thinking (see above).

What is the Medical Error Rate? For Charles Silver a Rate of even 1% is too much. A practitioner data bank says → 3 to 4 percent of all episodes of medical treatment in the U.S. result in injuries. What is the acceptable rate in your terms?

As per incentives when was the last time your insurer paid for your flight , or any other transaction that involved personnel with training skill and all that and you certainty agree that people never value someone else’s money as dearly as their own . You certainly didn’t pay the cost of your emergency room visit. Your insurer did. With a universal insurance policy, advocated by many of the ilk of this blog, will there be any incentive at all?

Who will give you the guidelines the same agencies who have taken money from the Pharma Companies and supposedly their middlemen (in a separate post in this blog). And which guidelines will be the perfect one with new information pouring in everyday.

And Charles Silver paid tribute to the people who brung him to dance by, canonizing trial lawyers, from whom any kind of error rate is acceptable and our holy cow justice system, can remain unscathed

But first things first the post which generated your long response, was addressing the traits that ‘bedevil all human beings’ and 15% misdiagnosis rate, its result. What kind of incentive going to change that? Medicine has a long way to go to be a rocket science , and new frontiers of research will change that making it as predictable as reproducible as evidence based , in future that we all hope for . But where does Charles Silver fit in?

Posted by: Anirban | April 9, 2007 2:35 PM

Groopman is from a Hate America venue, a left wing ideologue, devoid of credibility. Nothing coming from Harvard or its affiliates has the slightest credibility. Left wing, biased garbage is the best that can be said.

Let's accept his mistaken assumption, 15% of diagnoses are incorrect. His patient went to several specialists. Let's say she went to three. The chance of misdiagnosis after each evaluation is 0.15 X 0.15 X 0.15 X 0.15 or 0.05% including the misdiagnosis of her doctor. Groopman is typical of the Hate America left, in misrepresenting the facts. And the mentally crippling effect of law school allows the blogger to miss this misrepresentation. In his patient's case, the majority of her type of tumor are never diagnosed, and are incidental findings on appendectomy. The blogger failed to look that up on WebMD, due to bias.

This brings up the mathematically certain doctrine that what more than two doctors do is the standard of due care. That standard will always be seen as an outrage only within 10 years. As progress accelerates in its acceleration, that time will shrink. So what is done today will seem like surgeons refusing to wash their hands 100 years ago, only it will do so in 10 years. If you want to draw outrage, just cite a case from 10 years ago. That is always an easy cheap shot for the left wing extremist, biased, Harvard America Haters.

Posted by: Supremacy Claus | April 9, 2007 8:58 PM