Kate Adlington: Is there such a thing as the “right diagnosis”? Review from the Diagnostic Error in Medicine conference 2016

kate_adlington_picAs doctors, we probably already consider ourselves honorary members of the Society to Improve Diagnosis in Medicine (SIDM). It’s essentially part of our job description. But there is an option to become a fully paid up member. Founded in 2011 by US doctor Mark Graber, the SIDM is an international organisation that is dedicated to honouring all those who have been harmed by diagnostic error—aiming to create a “world where diagnosis is accurate, timely, and efficient.”

The society has hosted several international conferences on diagnostic error. June 2016 saw the first such conference to be hosted in Europe, with international healthcare colleagues travelling to the impressive Erasmus Medical Centre in Rotterdam, the Netherlands.

A hot topic of discussion was the recently published US Institute of Medicine landmark report on the problem of diagnostic error: Improving Diagnosis in HealthcareIt is sobering reading: 5% of US adults who seek outpatient care experience a diagnostic error each year and diagnostic error contributes to approximately 10% of patient deaths. It concludes that each of us is likely to experience one or more diagnostic errors in our lifetime.

The committee who produced the report also proposed a new definition for diagnostic error: “the failure to
• establish an accurate and timely explanation of the patient’s health problem(s) or
• communicate that explanation to the patient.”

They were explicit about their intentions to make this definition as patient centred as possible. And indeed it challenges the medical world’s concept of the “right diagnosis.”

No longer is it enough for doctors to spot the abnormality on the scan or make the correct interpretation of blood test results. If we don’t explain these results clearly to our patients in a way that they understand then we have got it wrong. We have made a diagnostic error.

The message is that diagnosis doesn’t end with a pat on the back because “we’ve got it right.” Apart from anything else, the diagnosis might not feel “right’ at all for the person sitting in front of us.

This is part of the ongoing identity shift for doctors from House style diagnosticians to person centred “holisticians,” who are concerned with patient experience rather than giving celebrated grand rounds presentations.

This new definition was largely welcomed at the conference. But for those involved in diagnostic error research, the broadened definition will pose an operational challenge that requires new study designs and outcome measures. The conference organisers committed to improving patient involvement in future to help identify what these desired outcomes might be.

Other interesting themes at the conference included the use of online tools to help aid diagnosis—particularly useful it seems in the case of rare diseases; the use of psychological theory to establish how individuals make diagnoses and where these thought processes might go wrong; and how system data, such as medical negligence databases, can help to identify where errors occur most frequently.

The research presented was varied and illuminating. One team in Switzerland explored why there is a high rate of change in individual patient diagnosis between admission and discharge. A British research group described how they are aiming to reduce “unclaimed” investigation results—tests that have been ordered, often in A&E or before a patient’s discharge, that are never checked or communicated back to patients, allowing potential diagnoses to go unnoticed. Another group is addressing the fact that a quarter of cancer diagnoses are made in emergency departments by seeing if there are missed opportunities for diagnosis in general practice.

Diagnostic certainty was discussed at length. It is rare that doctors can give a diagnosis to patients with 100% certainty. Could diagnostic error be exacerbated by overly confident assertions of the “correct” diagnosis? Might patients be less likely to question ongoing symptoms or return with their concerns if they’ve been inappropriately reassured?

Safety netting is one way of ensuring patients come back, but do we use it with patient wellbeing and safety in mind or as a way of absolving responsibility in case we’ve got it wrong?

Might being open and honest with patients, when we aren’t completely sure what’s going on, be the “right diagnosis”?

Kate Adlington is a clinical editor at The BMJ. Follow Kate on Twitter @kateadlington

Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.