Every American will experience a missed or delayed diagnosis at some point in his or her lifetime. Saying that is not a scare tactic — it's a reality, according to a 2015 National Academy of Medicine report titled "Improving Diagnosis in Health Care." Yet we have not made effective use of a simple solution: teamwork.
Among U.S. adults seeking outpatient care each year, 12 million are misdiagnosed. One in 20 hospital deaths results from a diagnostic error. Estimates suggest that costs of unnecessary tests, harms from misdiagnosis and legal payouts exceed $100 billion per year in the U.S. In short, inaccurate diagnoses are the most common, catastrophic and costly medical errors.
From a public health standpoint, we are in crisis.
Medicine is complex, and diagnosis is not an exact science, so we can’t always be right. But there is strong evidence that we can do a lot better than we do now. When we don't follow best diagnostic practices, we tend to undertest patients who need it most, missing chances to provide prompt treatments for dangerous disorders.
At the same time, we overtest patients who don't need it, wasting precious diagnostic resources on those with benign conditions. With more accurate diagnostic assessments, we can fix both problems — eliminating harms and reducing costs of care. For example, if we routinely followed evidence-based protocols for diagnosing dizziness in the ED, we could prevent 45,000 to 75,000 missed strokes each year and simultaneously save an estimated $1 billion per year.
The hospital and health care environments don't help either. High patient volumes, time pressures, interruptions, distractions and failed communication can all lead to a missed or delayed diagnosis. Then there is the fact that we are human. At times, we make a mistake in clinical reasoning, such as when we are presented with a unique clinical problem that is outside of our clinical expertise.
Physicians are tasked with diagnosing the patient's medical condition, but they are not the only ones who can ensure a correct diagnosis. Nurses, physical therapists, physician assistants and even family members may be the first to notice a change in the patient’s condition that indicates a wrong diagnosis. Sometimes nonphysicians have specialized knowledge critical to correct diagnosis. When armed with evidence-based diagnostic protocols and empowered to help physicians, these team members can ensure optimal diagnostic testing to maximize the odds of a correct diagnosis.
The National Academy of Medicine's report offers an immediate suggestion to improve health care diagnosis today: teamwork. The same principle that rules sporting arenas and playgrounds across the world can reduce the number of diagnostic errors. The practice of medicine has traditionally been a lonely and risky competition. Doctors are used to calling the odds and making diagnoses without input from other members of the team, and nurses and physician assistants are taught not to question them. If a physician makes a mistake, there is a culture of blame, shame and fear of litigiousness, which makes it less likely that individuals will speak up or report a diagnostic error.
But better teamwork achieves much more than merely changing professional norms or local work culture. I have witnessed its benefit to patients.
In an endeavor to challenge health care cultural norms and combat diagnostic errors, I mentored a colleague from another medical center, a physical therapist with 24 years of experience specializing in vestibular and balance disorders. In a paper published online May 31 in Diagnosis, we highlight five case studies where the physical therapist’s expertise proved paramount in correcting a misdiagnosis in patients who showed up to the ED with dizziness. Her expertise in performing a physical therapy vestibular assessment resulted in better treatment, better patient satisfaction and quicker discharge.
Initially, her relationship with physicians was strained, and they didn't value her input. She felt the pressure that many nonphysician health professionals feel in the face of doctors' authority: a need to back down or tread lightly to avoid the perception of disrespect. Over time, however, her position improved, and she built trust with her physician colleagues who now value her input, routinely consider her diagnostic findings and even ask to learn her techniques.
Shaking up health care culture to improve patient care isn’t a new concept, and there is proof that it can be done. Peter Pronovost, director of the Armstrong Institute and senior vice president for patient safety and quality at Johns Hopkins Medicine, created a comprehensive system that successfully reduced central line-associated bloodstream infections around the world. Empowering nurses to speak up was a critical yet simple component of the intervention. This system — put in place in 1,800 intensive care units across the nation — reduced these infections by more than 40 percent.
While nurturing more effective relationships and communication between physicians and other members of the health care team won’t prevent all diagnostic errors, this shift is a simple and affordable step in the right direction. A less hierarchical approach to "team diagnosis" would empower nurses, physician assistants and physical therapists to speak up and develop more collaborative relationships with physicians, who in turn will begin to rely on their input to help prevent misdiagnosis.
To my physician colleagues, I'll end with this simple advice: Pair up and offer mentorship to other members of your clinical team. Encourage them to pass along their expertise. Otherwise, we will miss a key opportunity to provide the best care to our patients, starting with an accurate diagnosis.
This post first appeared on The Health Care Blog.
Free webinar: "Diagnosis as a Team Sport"
Join David Newman-Toker from 1-2 p.m. EST on March 1, 2017 for a discussion how physicians can use teamwork — with patients, family members and other health care professionals — to improve diagnostic accuracy. Details and registration.
Excellent article about the importance of teamwork in delivering accurate diagnoses efficiently.
In my work as a rehabilitation specialist and case manager, I have found more resistance from physicians in acute care and outpatient settings than within rehabilitation facilities and programs where treatment tends to be routinely collaborative. Doctors who are overloaded and overwhelmed by the many demands of our changing healthcare system need a reason to make the effort and take the time to risk trying a new approach to patient care. I would respectfully offer that intellectually it is more interesting to discus a case with professionals who have varied backgrounds and training, because you benefit as a professional and healthcare provider by learning and considering the additional perspectives that others can provide. A physician who routinely collaborates or mentors may prevent errors by broadening their list of treatment choices and tag teaming with other specialists who may recognize a wider range of options. In turn, the added time that a doctor expends through the collaborative or mentoring process minimizes the time required to manage a medical crisis brought about by medical errors avoided. Lastly, patients are much more willing to trust a physician who is willing to be open to the opinion of a colleague or other healthcare professional, because they are practicing with transparency. Teamwork is a win-win for patient, doctor and the overall treatment process.
Dr. Newman-Toker,
Thank you for your excellent article. I wonder if we physicians should attend courses like the "Dale Carnegie Course" during medical school. I hope one day somebody will study the clinical impact of physicians attending this or similar courses. I bet it will prove that you are correct: by improving teamwork, we will improve diagnostic accuracy and improve patients' satisfaction with their treatments.
Thank you for this piece. Spot on. Thank you for the work you to ensure safe patient care. I lost my
Dad to misdiagnosis in 2014. As an RN of 22 years, I knew he was in heart failure and not pneumonia dx. I wasn't listened to until I threatened a lawyer. By then, my Dad was in multi-organ failure.
Same as the co-pilot speaking up rather than witnessing a disaster. I am a huge advocate of a team approach; but am a voice in the wilderness it seems.
The excellent book "Why hospitals should fly" described this recommendation years ago and so sad it still hasn't been more accepted by the medical community.
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