Helping doctors help themselves

Dr. Jerome Groopman, chief of experimental medicine at Beth Israel Deaconess in Boston, has a good article today in the Globe (The mistakes doctors make. Errors in thinking too often lead to wrong diagnoses.)

According to Groopman:

Misdiagnosis occurs in 15 to 20 percent of all cases…and… in half of these, serious harm occurs.

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.

The 15 to 20 percent figure is unacceptable, especially when we think of the financial costs and the toll in patient suffering. Groopman points out that few clinicians understand their own thought process –which isn’t so surprising. A top-notch physician I know somewhat sheepishly describes his style of thinking about patients as “mulling.”

I’m passionate about shortening the diagnostic odysseys that patients often endure before finding the right diagnosis and am an adviser to SimulConsult, which makes a decision support software program that also does a bit of “mulling.” But because it is a computer program no one is sheepish about vagueness of process.  The program can consider far more diseases than a person can. It can also suggest additional findings that would be useful to check. It does away with the problems of “premature closure” and “confirmation bias” Groopman cites.  Medical educators are attracted to using the software to make explicit the cognitive processes that doctors should be learning.

We can interrupt the cascade of cognitive mistakes and return to an open-minded and deliberate consideration of symptoms, physical exams , and laboratory tests — and in this way close an important gap in care.
Cognitive insight alone is not a full solution.  It is hard to keep that many possibilities in mind without using software, and contrary to the article there are indeed many cases in which the problem is “lack of knowledge about what later is found to be the underlying disease.”
March 19, 2007

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