Medical Mistakes, Pt 2: The Missed Diagnosis

Medical providers are trained to make careful and systematic diagnoses. Sometimes we are right; sometimes we are not. Since we make thousands of diagnoses per year, it is not unusual to miss a few. To be in medical practice is to tolerate ambiguity, because not all diagnoses are straightforward. Neither are patients.

A diagnosis is made by the medical history, the physical examination, and diagnostic tests; none of which are 100% perfect. Clinicians need to ask the right questions; patients need to provide honest and complete answers. It is said that if you listen to a patient's story long enough, they will give you the diagnosis. Sometimes this is true; sometimes the patient's diagnosis is way off base. The medical history is critical to formulating an accurate diagnosis; it should be complete and unbiased.

Patients and providers often have mismatched expectations. Patients expect to be seen on time and be on their way in a timely fashion. Unfortunately, patients are often scheduled for a mere fifteen minutes and sometimes less in a busy practice. In a real world, providers would love to guarantee timely visits; unfortunately we never know what is behind Door #2, or what was behind Door #1 that put you behind in schedule in the first place. Patients expect to be quickly and accurately diagnosed, but this too, is often not possible in just one visit. So, when providers (or patients) are rushed, mistakes are more likely.

Patients often do not give the whole story. Providers often do not listen. When a patient presents with headaches, there are numerous questions that need to be addressed. When did it start? How long do they last? Where are they located...exactly? (The typical response is "in my head")

Are you taking any medications? Do you smoke? And, so on. If you fail to mention that your father died of a brain aneurysm...even if the clinician fails to ask this vital question...an accurate diagnosis may not be made.

I have to say that some providers do not even give the patient a chance to tell their story. They interrupt. They cut you short when they feel they have the answer. I once had a patient tell me that "Dr. Smith is very smart. He diagnosed my sinus infection seconds after he walked in the room. He didn't even need to examine me!" This "treat 'em and street 'em" approach to fast-food medicine can result in terrible outcomes, if that "presumed sinus infection" turns out to be something more ominous.

Patients often have their own agendas. "I have a sinus infection and just need antibiotics." It has been said that a person who diagnoses themself has a fool for a doctor.

If you are paying for the expertise of a medical provider, allow them the opportunity to make their own assessment of your problem. You may be surprised that it differs. If your preconceived diagnosis matches your medical provider's assessment, then everyone will be happy. In clinical practice, it is much easier to just hand a patient the prescription they want, rather than take the time to explain that (a) they do NOT have a sinus infection, and (b) colds do not require antibiotics.

Patients often present with peripheral issues. "Oh, by the way..." When the patient who presents with a particularly troublesome headache, it can quickly become diluted when they whip out a suspicious dark mole, or point out the bunion on their feet.

There is only so much medical care that can be provided in one visit. Although you may feel it is cost-effective to try and get years of medical complaints addressed at one visit, this is a set-up for misdiagnosis.

Good medical care is not cheap. For instance, the Gold Standard for assessing the status of a person's sinuses is a sinus CT scan. Every person who presents with the classic symptoms and signs of a sinus infection will not necessarily need this expensive diagnostic study, but sometimes it is needed.

Many insurance companies put cost constraints on medical providers, so in order to get this needed CT scan; we may have to go through an exhaustive dance with the health plan. Additionally, not all sinus infections can be treated with cheap, generic drugs. Some will require bigger guns, and a bigger bill to the insurance company or the patient. Trying to save a buck can sometimes often result in misdiagnoses and poor outcomes.

Physical examinations miss things. A common question on the WebMD Ear Disorders board concerns vertigo/dizziness. "My doctor looked in my ear and said that every thing looks fine." There are literally HUNDREDS of causes of dizziness, and only a few of the causes can be seen by simply "looking in the ears". When a clinician fails to find an obvious cause for a person's symptoms, it is their continuing responsibility to keep looking, or to send you to someone (like a specialist) that will. The clinical signs of Strep throat are well-known, but even with my 30+ years of clinical experience; I can still miss one that isn't classic or obvious. Taking that one additional step of doing a throat culture will increase the accuracy of a clinical assessment.

Diagnostic tests miss things. A man comes in with recurrent chest pain. The history is suspicious in that he has pain on exertion; his father has heart disease.

The physical examination reveals that his heart sounds "just fine". His electrocardiogram is read as "perfectly normal". He is told that his chest pain is most likely just gas. A few days later, he dies of a coronary infarct -- a heart attack. His wife and three kids are not happy about this misdiagnosis. Their attorney salivates at this story. To err is human; to be sued is not divine.

In retrospect, perhaps a cardiac stress test or an angiogram would have saved this man's life. Retrospection does not bring back a life.

All medical providers practice defensive medicine; some more than others. However, when medical providers fail to order those additional tests, regardless of the reasons, a misdiagnosis may occur -- a deadly mistake.

Your medical provider is your partner in care. When mistakes are made, there are often two parties that are responsible. Effective communication is the key. Medical providers are not perfect, even though some feel that they are. Mistakes will happen. The only thing you can do as a consumer to limit those inevitable mistakes is to take an active, participatory role in your health care. Your doctor is merely a travel agent...you are the one taking the journey.

Related Topics: 7 Key Traits of the Ideal Doctor, Health Simplified: 8 Steps for Healthy Living

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