Last month, I attended a meeting in Atlanta on causes of diagnostic errors and ways to avoid them. This annual meeting is sponsored by the Society to Improve Diagnosis in Medicine, a small organization with the lofty goal of eliminating errors in diagnoses.
As a generalist specialty, family medicine faces more diagnostic challenges than any other specialty because we see so many undifferentiated problems. However, only 2 family physicians attended this meeting: I was one, because of my research interests in proper use of lab testing, and John Ely, MD, from the University of Iowa, was the other. He has been researching diagnostic errors for most of his career. One physician/researcher has developed a note card diagnostic checklist that he goes through like a pilot before takeoff. Dr. Ely has been testing an idea borrowed from aviation: using a diagnostic checklist. He developed a packet of note cards that lists the top 10 to 20 diagnoses for complaints commonly seen in family medicine, such as headache and abdominal pain. Before the patient leaves the exam room, he pulls out the appropriate checklist and goes through it out loud, just like a pilot before takeoff. He says for most patients, this process is pretty quick and it reassures both them and him that he has not missed an important diagnosis. (You can download Dr. Ely’s checklists from http://www.improvediagnosis.org/resource/resmgr/docs/diffdx.doc.)
How are the rest of us avoiding diagnostic errors? Some day IBM’s Watson or another diagnostic software program embedded in the electronic health record will guide us to the right diagnosis. In the meantime, I have developed a list of 7 low-tech ways to arrive at the correct diagnosis (and to rapidly correct a diagnostic error, should one occur):
1. Listen carefully to the patient’s story without interrupting. This is the quickest path to the correct diagnosis. 2. Find out what dreaded diagnosis the patient believes he or she has so you can rule it in or out. 3. Don’t forget the pertinent past history. It makes a big difference if this is the patient’s first bad headache or the latest in a string of them. 4. Don’t skip the physical exam; even a negative exam, if documented properly, may keep you out of court. 5. Negotiate the diagnosis and treatment plan with the patient. This often brings out new information and new concerns. 6. Follow up, follow up, follow up, and do so in a timely manner. 7. Quickly reconsider your diagnosis and/or get a consultation if things are not going as expected.