ARTICLE IN BRIEF
In response to the Institute of Medicine Report, “Improving Diagnosis in Healthcare,” neurologists involved in patient safety issues discuss common reasons for misdiagnoses in neurology and how neurologists can address them.
A 72-year-old patient went to a clinic complaining of weakness in his arms and legs, adding that he was tired at the end of the day. He had experienced a stroke two years earlier and recovered, but the CT scan and MRI of his brain showed no signs of a repeat episode. So he was sent home.
About two weeks later, the patient returned to the stroke clinic, this time seeing David Z. Wang, DO, FAHA, FAAN, director of the Comprehensive Stroke Center at OSF Saint Francis Medical Center in Peoria, IL. The patient had the same complaints: weakness in his arms and legs and extreme fatigue at the end of the day.
“These complaints sounded like a typical neuromuscular junction problem, so I started looking in a different direction, at myasthenia gravis,” said Dr. Wang, a professor of neurology at the University of Illinois School of Medicine in Peoria.
“The patient is now fine, and he's very appreciative,” said Dr. Wang. He said the previous doctor misdiagnosed the condition because he was so focused on the stroke the patient had had two years earlier, and this was unrelated.
INSTITUTE OF MEDICINE REPORT
In an Institute of Medicine (IOM) report released in September, researchers declared diagnostic errors as the “blind spot” in health care, contributing to 10 percent of patient deaths and 6- to 17-percent of all hospital adverse events.
Data from the Physician Insurers Association of America (PIAA), the insurance trade association representing medical professionals, suggest neurology is not immune. According, to the PIAA MPL Specialty Specific Series for Neurology 2014 Edition, diagnostic errors were the most prevalent factor in neurology claims and lawsuits, and were cited as the primary issue in nearly one-third of claims closed between 2009 and 2013.
Among those closed claims and lawsuits, approximately 32 percent resulted in an average indemnity payment of $539,598. Top patient outcomes related to diagnostic errors that resulted in an indemnity payment were occlusion of cerebral arteries; acute, but ill-defined cerebrovascular disease; and encephalopathy, according to the analysis.
The IOM committee concluded that most people will experience one diagnostic error in their lifetime, but bemoaned the lack of data measuring diagnostic process and errors.
To improve those numbers, the report suggested more of a teamwork approach to diagnosis, including more collaboration between health care professionals, providing patients with the tools to be more involved with the diagnostic process (such as, for example, finding errors in their electronic medical records), and encouraging more research.
HOW TO ADDRESS DIAGNOSTIC ERRORS
Amar Dhand, MD, DPhil, an assistant professor of neurology at the Washington University School of Medicine in St. Louis, called the report “a landmark study.”
“It's a prevalent and serious problem. There aren't a lot of mechanisms to monitor the issue so we can sway the tide and stop it from happening,” said Dr. Dhand, who coauthored an analysis of clinical decision-making among community-based neurologists in Neurology in 2013.
Dr. Dhand said part of the issue is that a misdiagnosis may play out over time; physicians often don't find out that they made an error because the patient has moved on.
And one of the challenges with the teamwork approach is that not everyone is part of a larger group, he said. Private practitioners tend to be more solo artists, looking at neuroimaging and lab work and working off comments left in the electronic medical record (EMR).
Academic groups have different problems. They may participate in more of a shared process of decision-making, but sometimes the work is left to trainees who do the initial intake and may miss something significant.
“Because of the different social systems, each has different vulnerabilities,” said Dr. Dhand. “The private practitioners are vulnerable because they may get into a routine or a habit of seeing things a certain way, and they are not as challenged by other neurologists.
“In academia, you may not get all of the information. There's a detail voltage drop at every pass off, and the follow-up is distributed across physicians so feedback of the end result doesn't make it to everyone.”
Dr. Wang, who co-chairs the AAN Quality and Safety Subcommittee, agreed that a lack of time with patients and the need to supervise interns and residents can contribute to more errors or misdiagnoses. He added that the overemphasis on imaging and not enough focus on a taking a detailed patient history and performing a physical, as well as doctor bias or stereotyping toward certain populations can also contribute to misdiagnoses.
“If a patient comes in and they are overweight [or they appear to have a drinking problem], the physician may just automatically blame the problem on their weight or their drinking. These patients may still have other neurological problems — a brain hemorrhage, for example, or an infection such as meningitis. If someone comes to the emergency department three or four times, they may be viewed as a repeater who is seeking attention, when they may possibly have other serious conditions such as a malignancy or stroke.”
EMRs help, but they also cause problems, he said. “We all see many patients a day, and the radiology report might be buried in the EMR and may not have been flagged. It's important for the radiologist to call the treating physician with the findings or diagnosis. This dialogue is very important in helping clinicians to make a correct diagnosis.”
At Washington University, he said, physicians created a diagnostic monitoring tool where neurologists must outline the process used to make a diagnosis, from physical exam and patient history to lab work and scans.
Eric Cheng, MD, FAAN, the interim chief medical informatics officer and an associate professor at the David Geffen School of Medicine at the University of California, Los Angeles, said it is very difficult to develop quantifiable quality measures regarding a diagnosis, because symptoms are not recorded as discrete data. For example, “difficulty walking” may be a symptom of Parkinson's disease, but it is not specific enough. It would not be appropriate to ask physicians to document why every patient with difficulty walking does or does not have the diagnosis of Parkinson's disease, he said.
While electronic health records make it easier to propagate information, they also make it harder to correct misinformation.
“Once a physician records a diagnosis, it can become really, really hard to reverse it. Let's say PCP A makes an incorrect diagnosis. Specialist B copies that diagnosis into a note. Specialist C (let's assume this is the neurologist) makes the correct diagnosis. PCP A reads the neurologist's note and does the right thing in correcting the diagnosis in his or her note,” Dr. Cheng said. “But if specialist B copies his or her own previous note with the wrong diagnosis, it still remains [in the record].”
“As part of a grant sponsored by a disease specialty society, I interviewed patients about their care,” Dr. Cheng said. “I thought they would most want to discuss their quality of care or access to specialists. I was surprised that quite a few patients wanted to express their anger about being initially misdiagnosed. Even if they believed they were currently receiving good care, they still harbored mistrust of the health care system because of those early experiences.”
IOM: RECOMMENDATIONS FOR IMPROVING DIAGNOSES
The Institute of Medicine report, released last September, recommends these among other recommendations for improving diagnosis in health care:
- Facilitate more effective teamwork in the diagnostic process among health care professionals, patients, and their families.
- Enhance health care professional education and training in the diagnostic process.
- Ensure that health information technologies support patients and health care professionals in the diagnostic process.
- Develop and deploy appropriate approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice.
- Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance.
- Develop a reporting environment and medical liability system that facilitates improved diagnosis by learning from diagnostic errors and near misses.
- Design a payment and care delivery environment that supports the diagnostic process.
- Provide dedicated funding for research on the diagnostic process and diagnostic errors.
To download the full report and to find additional resources, visit nas.edu/improvingdiagnosis.