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Narrow Minded

By Jock Hoffman, CRICO

Related to: Diagnosis, Emergency Medicine, Primary Care, Obstetrics, Other Specialties, Surgery


Diagnostic fixation errors were a factor in 14 percent of the malpractice claims and suits asserted against CRICO-insured clinicians and institutions over the past five years. Those 180 cases account for $137M of incurred losses (22 percent of the CRICO total for the same time period). More than 74 percent of those 180 events involved a high-severity injury (or death). The largest percentage of those cases involved outpatients, and the most commonly missed diagnosis was cancer.

Because hindsight is 20/20, the factors that led to a missed or significantly delayed medical diagnosis often seem starkly conspicuous in retrospect. What is frequently obvious to the belated observer is that the physician made a quick and confident diagnosis and then never looked back. Despite contrary evidence and unsuccessful therapy, the physician held fast to the initial diagnosis. Only when forced to by either persistent symptoms, subsequent test results, or a contrary second opinion, did the physician recognize that he had failed to explore beyond his initial conclusion…too late for the patient and, perhaps, too negligently for a malpractice trial jury.

Malpractice suits, while troublesome, are relatively rare; diagnostic errors are fairly common—by some estimates up to 15 percent of diagnoses are erroneous. Decision support tools and better systems to enhance a physician’s follow-through and follow-up can help physicians reduce systems-based diagnostic errors. But the challenge of helping physicians avoid tunnel vision remains more daunting. First, many of the cognitive functions that set up occasional fixation errors also enable consistently accurate diagnoses. Second, diagnostic errors can go undetected for months, sometimes years. Without a timely (and non-punitive) feedback process, physicians find themselves at a loss for understanding when their skills have misled them. And, without that awareness, their ability to develop preventive tactics is greatly compromised.

Unfortunately, effective solutions to reduce errors of narrow diagnostic focus remain elusive. Experts studying diagnostic errors have proposed a wide range of strategies for addressing the fixation problem, but none has yet been widely adopted. We invite you to explore them and let us know which, if any, are worth further consideration.

October 1, 2008
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