Diagnostic Inaccuracy in Primary Care: How Much Can We Blame the System?

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

The search for a scapegoat is the easiest of all hunting expeditions.”
-Dwight D. Eisenhower

Part V in Series on Diagnostic Accuracy

Case Example: A 45 year old woman sends a secure electronic message to her primary care clinician, asking what she should do for her “heartburn.” Her PCP works a 3 day per week schedule at a chronically understaffed rural health center, and finally gets to the patient’s message at the end of a long day. The PCP does not ask any additional questions, but suggest the patient try OTC famotidine for a few days and call back if the “heartburn” is no better. Two days later, the PCP receives an electronically communicated consultation note from the local hospital, that the patient was admitted to the ICU in cardiogenic shock from a massive myocardial infarction. Glancing through the electronic health record, the clinician notes that the patient’s mother and father both died in their 40s of heart attacks.

This case of diagnostic error is certainly partly due to the PCP not performing an adequate assessment of the patient: not reviewing the electronic health record for background information, not asking additional questions to find out what the patient meant by “heartburn” or asking about red flag symptoms.

However, several system issues also contributed to the diagnostic errors: the overworked clinician, more prone to shortcuts to get through their day; the PCP’s reduced in-office schedule; the promotion of electronic communication to increase access to clinician; the lack of the PCP’s experience with rarer but more serious causes of “heartburn” because an emergency room/hospitalists sees all patients in the hospital.

The Institute of Medicine’s 2015 book “Improving Diagnosis in Health Care,” categorizes such system issues that contribute to diagnostic inaccuracy into five groups:

  1. Organizational factors, such as schedules, staffing models, payer mix, and leadership.
  2. Physical environment, including clinical ambiance, proximity to co-workers.
  3. Tasks, which may compete for the attention of the clinician, like electronic medication refills, or which may not occur when they need to, like following up abnormal lab results.
  4. Technologies and tools, such as the configuration of the electronic health record, and the use of electronic modalities for virtual care.
  5. Diagnostic team members, including who is included on the team (adding a triage nurse for example), how communication occurs with the team, and the sense of responsibility team members feel to collaborate (in the case above, none of the physicians caring for the patient in the hospital called the PCP about the admission).

These same five factors contribute to clinician burnout and to health care inequities, so we as clinician leaders have a triple responsibility to spend our discretionary time working to steadily optimize this work system, the external environment that our clinicians work within. This is true for all clinician leaders, whether we work in primary care, specialty care, institutional settings like hospitals or skilled nursing facilities, at a health plan, or a government regulator.

At the same time, individual clinicians must continually strive to improve their own diagnostic processes, being aware of their own cognitive biases and short cuts, and reinforcing a sense of professional responsibility to achieve diagnostic excellence even with the shortcomings of the system we work in.

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