Who Shoulders the Blame for Misdiagnoses?: Op-Ed

Richard Anderson is chairman and chief executive officer of medical malpractice insurer The Doctors Company and past chairman of the Department of Medicine at Scripps Memorial Hospital in La Jolla, Calif. He contributed this article to LiveScience's Expert Voices: Op-Ed & Insights.

The recent revelation that missed or wrong medical diagnoses are the most common and costly of all malpractice claims would seem to point the finger squarely at physicians to fix this daunting problem.

Most people reason, after all, that misdiagnoses stem from individual doctors' mistakes. The study published on April 22 in the journal BMJ Quality & Safety does lay out formidable numbers: Diagnostic errors have cost $38 billion in malpractice claims over the past 25 years and were the leading cause of claims associated with death and disability.

But solely zeroing in on doctors in the effort to decrease such errors — which, no doubt, have a significant impact on patients and their families — fails to look at the bigger picture. First, while researchers analyzed nearly 1 million malpractice claims over a quarter-century, we should remember that millions of doctor-patient encounters occur every single day — and the overwhelming majority occur without incident. [Doctors Really Do Feel Your Pain]

Second, there are essentially only two types of malpractice claims: those relating either to diagnosis or treatment. So, learning that many of those pertain to diagnostic errors, while disconcerting, is not a revolution in thinking. We shouldn't be shocked to learn that we need to get the right diagnosis in order to get the right treatment.

A classic example of overfocusing on the doctor's role is the call to crack down on physicians' illegible handwriting. This is an utterly sensible idea because bad handwriting can cause prescription errors. But ultimately, we don't need to turn every physician into a calligrapher. We need to concentrate on the desired outcome — every patient getting the right medication and then actually taking it as directed.

Medical mistakes can happen in dozens of ways, with a significant percentage triggered by patients who, for a variety of reasons, don't follow doctors' recommendations.

Patients can help reduce diagnostic errors by providing their doctor with an accurate medical history, adhering to the prescribed follow-up plan, keeping return visit appointments to discuss abnormal test results, and asking questions to clarify instructions they don't understand.

When we say we need to drill down on the nature of diagnostic errors, I agree. We need to eliminate them to the extent that's humanly possible, but medical treatment isn't a machine science. If we have learned anything in the past decade or so of medical research, it is the staggering biologic complexity of human beings, which is made vastly more difficult by the infinite harmonics of nature and nurture. The ambiguity presented by this complexity is an enormous challenge. Both physicians and patients need to work together, using all the resources available, to reduce the circle of potential error.

In cases of doubt, ambiguity or high risk, consultation with appropriate specialists is advisable. The same is true for unusual diagnoses: If a doctor hasn't seen a similar case since medical school, then by all means, send the patient on to another physician who sees such ailments regularly. [Rare Diseases Obscured by Shadows of 'Popular' Ills: Op-Ed]

In addition to traditional sources of medical information, doctors now have some remarkable and highly accessible online tools available to increase the likelihood of correct diagnoses. One example, UpToDate — an evidence-based, peer-reviewed informational website that helps support clinical decisions — is readily available with a few strokes of the keyboard.

Physicians need to assure their work is supported by appropriate processes and procedures all along the chain of responsibility. This includes everything from tracking laboratory and imaging studies to follow-through on appointments and coordination of medical records among the entire care team. Even a simple tickler file, employing numbered folders to remind medical staff to follow up on tests and appointments, can be very useful. A truly integrated medical record is even better.

Beyond doctors and patients, we must acknowledge that our fragmented health care system must share in the responsibility for many diagnostic mistakes. In an ideal world, if a woman has an abnormal mammogram, for instance, the system will have many checks and balances to make sure appropriate action is taken. But to the extent that individual office practices, or radiology suites, or surgicenters, or hospitals work in complete or partial isolation — the case with much of American health care — it's not surprising that many things fall between the cracks. The failure to create uniform electronic medical records for all Americans is a huge contributor to the problem.

Successful integration of medical records and consistent national standards remain a holy grail for improved patient safety. Since hundreds of versions of electronic medical records exist today, even doctors, hospitals and pharmacies that use electronic records often don't communicate electronically with each other, negating much of their benefit. A truly integrated, electronic, medical-records system is the single greatest engine to drive enhanced medical outcomes that I can imagine right now.

On another level, the medical malpractice system itself is broken, negatively affecting patients and physicians alike. A national study by the RAND Corporation published in the January issue of the journal HealthAffairs and based on The Doctors Company data shows that the average physician spends more than 10 percent of their career fighting unresolved malpractice claims. For some higher-risk specialties like neurosurgery, that figure is 25 percent. This is time physicians should be spending on caring for patients.

Moreover, approximately 80 percent of those claims are frivolous or fruitless and don't result in any payment whatsoever, but each is enormously costly to defend. Billions of dollars go into litigation costs because our medical legal system wrongly assumes that medical error can be prevented by punishing individual physicians in isolated circumstances. The four-decade legal assault on the medical profession has utterly failed to make medicine safer, and it's time we focused not on shame and blame, but on ways to make our health care system work better and smarter.

The views expressed are those of the author and do not necessarily reflect the views of the publisher.

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