The Cost Of Assuming Your Doctor Knows Best
“The Good Doctor,” a TV series on ABC, debuted earlier this fall with a neat trick. Dr. Shaun Murphy, an autistic savant, saved a little’s boy’s life with two brilliant diagnoses. I cringed.
Most doctors are not geniuses, but even geniuses make mistakes. As a diagnostician myself, I’d like to believe I’ve made some good, even great, diagnoses in my day. But patients need to spend more time focusing on a more important issue: physician error. Physician errors hurt patients, and unless those of us who are physicians own up to our mistakes, discuss them, and learn from them, we end up endangering more lives.
My biggest mistake (that I know of) happened early in my practice. I am a pathologist. I diagnose disease by looking at tissue cells under the microscope. In this case, I missed the cancer cells on my 42-year-old patient, causing her cancer diagnosis to be delayed. She eventually died of her cancer.
I never met her — pathologists rarely meet their patients — so, I do not know if she was told that her doctors, both the clinician and pathologist, had missed earlier signs of her cancer. We, the doctors, did not talk to each other about the missed diagnosis.
Doctors wear an impenetrable mask of supreme confidence and of always being right. Admitting a mistake is an admission of failure. Discussing one is worse still. Everyone would know that I had made a mistake. I might get sued, causing me both potential financial and professional harm. And so, I kept quiet. In so doing, I may have even caused more harm.
Fifteen years later, this woman’s cancer became one of a small group of cases that were used to define a difficult-to-diagnose cancer. Had I shared the story of my own inability to correctly diagnose this woman, might we have been able to describe this type of cancer sooner and perhaps saved several other women from a similar plight? I will never know.
We have since started talking more openly about mistakes in medicine. In the 1980s and 1990s, a number of shocking stories of medical error, followed by the Institute of Medicine report on medical error in 1999, jumpstarted the quality and safety movement in medicine. The medical profession focused on improving processes and putting in safety measures to reduce the occurrence of medical error. And it worked. The number of medication errors, wrong patient and wrong-side surgeries, retained surgical objects and hospital-acquired infections dropped drastically.
When we simply cannot overlook the fact that we did make a diagnostic error, we feel intense guilt and shamefully hide the error. We most certainly do not discuss them, or report them, or log them.
But one type of error remained untouched: the diagnostic error. Just as individual doctors did not want to discuss their mistakes, the medical profession also chose to ignore diagnostic errors even as it tackled these other problems.
The decision to ignore diagnostic errors during this period of reforms is a costly one that has harmed patients. The diagnostic error is a medical mistake that results in an incorrect or a delayed diagnosis for the patient. Making the final diagnosis is the doctor’s responsibility. The doctor pulls together all the pieces of information, including history, signs, symptoms and test results, to name the disease that is the cause of the patient’s malady. It is that label, that diagnosis, which will accompany the patient through her health care journey and determine what will happen to her.
A lot rests on that diagnosis, and the doctor takes full responsibility for it. And the good doctor does not get that diagnosis wrong, ever. Because that is what we believe defines being a good doctor. And so, as doctors, we convince ourselves that we do not make diagnostic errors. When we simply cannot overlook the fact that we did make a diagnostic error, we feel intense guilt and shamefully hide the error. We most certainly do not discuss them, or report them, or log them.
The National Academy of Medicine (formerly the Institute of Medicine), came out with a report on diagnostic error in 2015 identifying diagnostic error as the most harmful and most expensive of medical errors. It is estimated that between 40,000 to 80,000 deaths occur in the U.S. from diagnostic error and that as many as 17 percent of diagnoses are inaccurate.
The report raises another worrisome metric — that diagnostic error is perhaps on the rise because of the increasing complexity in medicine. Doctors face increasingly higher caseloads and administrative burdens. Keeping pace with changes in medical knowledge is ever more challenging; it is estimated that medical knowledge will double every 73 days in 2020.
We are more likely to miss something critical for making the right diagnosis in this new fast-paced world. Medical professionals, therefore, need to come up with measures that will help us make the right diagnosis. Computers and artificial intelligence will necessarily feature in big ways to help us capture and sift through information and make the right diagnosis.
But first, we need to log and catalog these errors, so we can study how and why they happen. Only then will we be able to devise strategies to reduce harms from diagnostic error. For that to happen, we have to start talking about these errors and sharing the lessons learned when we experience one. We need to get rid of the stigma of error among physicians and provide support and education for them. We need to take on diagnostic error, as we did other medical errors in the early 2000s.
So, although a doctor who gets the diagnosis right every time makes for good TV drama, in the real world, the truly “good doctor” is one who makes mistakes, acknowledges them, and learns from them.