Author: Dr. Antonio Medina. Dr. Medina is a
The doctor and his staff sway in the small room, approach the blackboard, write scribbles, talk non-stop, often irascible and inconsistently, but after a few minutes Eureka !, this is a strange and serious illness, and if it is not treated in time it will be deadly. We speak about Dr. Gregory House,
a television icon, a genius of medicine and diagnosis. He is praised for his insight and ability to unravel the most complex diagnosis, but never for his compassion or humanity.
Have you ever said: ” Would you rather have a doctor who will hold your hand while you die or one who ignores you while you improve? Although I think the worst would be one that ignores you while you die ” Is Dr. House a model to follow? We are drawn to difficult diagnoses, and we love to unmask the mysteries of medicine. Many times we see a challenge and not a patient, even knowing that it embodies a son, a mother or a family. A diagnostic mistake, takes us away from the superdoctors like House, but brings us closer to our own humanity, sensitizes us, feeds us, teaches us to blows. Studying the diagnostic error is a difficult task, because we have to analyzing and debugging huge amounts of material in medical records, undergoing medical audits, and, in general, it is not a pleasant process.
Underreporting, conscious or not and the tendency towards protectionism of our colleagues and of ourselves makes difficult the work to quantify and qualify the diagnostic error and, of course, the most important thing, reduces our ability to identify health risk in our patients, often creating false security. A practical example is presented by Singh et al (1) in JAMA, describing that a little more than 80% of the clinical records in primary care in which diagnostic error was detected did not have a differential diagnoses.
Medical services such as emergency rooms, operating theaters and intensive care units, are subject to heavy workloads, with critically ill patients, in which life saving is the most important concern
Therefore the correct diagnosis can suffer delay with the consequent negative effect on the health of the patient. On the other hand, other specialties such as radiology or pathology also suffer from diagnostic error.This fact is magnified when the clinician gives the findings of these specialties “absolute certainty”, even though many tests are known to be operator-dependent. Particularly important is the case of primary care, an area in which a wide variety of factors come together, influencing the genesis of the diagnostic error. In the area of primay care the factors involved in a diagnostic error are related to the administrative burden, the expectations and demands of the patients, the indiscriminate derivation to the hospital. An important aspect in this area is the pluripathological patients, where several specialties are involved, but there is no a coordinated teamwork. In short, primary care is a place of high risk for diagnostic error also together with the tertiary level.
It is not enough to admire House. Increase patient safety and reduce diagnostic error, it is an arduous task, which requires a lot of work, discipline, organization and a systematic effort.
- Singh H, Giardina TD, Meyer AND, Forjuoh SN, Reis MD, Thomas EJ. Types and Origins of DiagnosticErrors in PrimaryCareSettings. JAMA InternMed.2013;173(6):418-425. doi:10.1001/jamainternmed.2013.2777