I’ve had a keen – some might say obsessive – interest in the subject of medical misdiagnosis ever since a man with the letters M.D. after his name sent me home from the Emergency Department in mid-heart attack. I had just been misdiagnosed with acid reflux – despite presenting with textbook cardiac symptoms.
These included crushing central chest pain, nausea, sweating, and pain radiating down my left arm. How can modern medicine still be making such potentially deadly misdiagnoses like this?
Dr. Charles Pilcher is a Washington State physician who’s also spent a great deal of time thinking about this very question. A veteran emergency medicine doc and a medical missionary in Honduras and Kenya, Dr. Pilcher knows a lot about the potential devastation of a clinical misdiagnosis.
In a recent essay, Dr. Pilcher cites some scary factoids. For example:
about 5% of autopsies find clinically significant conditions that were missed and could have affected the patient’s survival
40% of medical malpractice suits are for something called “failure to diagnose”
nearly one in three reported adverse events involve diagnostic errors, and more than 10% of these mistakes result in death
According to Dr. Pilcher, these errors are rarely system errors (like mis-filing a pathology report that shows a tumour is malignant) but are more often thinking errors.
He believes that there are several reasons why we make mistakes in our thought processes even when we have the knowledge and ability to think correctly. He points to a 2003 report(1) in the journal Academic Medicine that lists seven examples of these identified thinking errors, including:
Anchoring bias – locking on to a diagnosis too early and failing to adjust to new information
Availability bias – thinking that a similar recent presentation is happening in the present situation
Confirmation bias – looking for evidence to support a pre-conceived opinion, rather than looking for information to prove oneself wrong
Diagnosis momentum – accepting a previous diagnosis without sufficient skepticism
Overconfidence bias – over-reliance on one’s own ability, intuition, and judgment
Premature closure – similar to confirmation bias, but more “jumping to a conclusion”
Search-satisfying bias – the “Eureka!” moment that stops all further thought
In Dr. Pilcher’s opinion, the most fascinating and most common of these is “anchoring bias”, which means “locking on to a diagnosis too early and failing to adjust to new information”.
This seems precisely what happened to me during that first trip to the Emergency Department. When the first of two standard cardiac enzyme blood test results came back “normal”, my white-coated M.D. told me with an air of profound certainty:
“Your first cardiac enzyme blood test is normal. We’ll do one more blood test – and that one will be normal, too.”
But even before that second blood test was done, he looked me up and down and pronounced that I appeared to be in “the right demographic” for an acid reflux diagnosis. He never wavered from that misdiagnosis after almost immediately “locking on” to it.
In fact, this physician was so sure that my problem was NOT heart-related that he sent me home from Emergency within five hours of the onset of my symptoms – a far shorter period of observation than clinical practice guidelines dictate.
Worse, after we asked him: “But what about this pain down the left arm?” (which even I knew was not a symptom of heartburn), the nurse sternly scolded us privately to stop asking questions of the doctor.
“He is a very good doctor. And he does not like to be questioned!”
It turns out that I was not alone in being misdiagnosed and sent home from hospital due to such examples of anchoring bias. According to a study reported in the New England Journal of Medicine, women in their 50s and younger are seven times more likely to be misdiagnosed during a cardiac event and sent home from Emergency compared to our male counterparts.(2) See also: How Can We Get heart Patients Past the E.R. Gatekeepers?
As thinking errors move to the forefront of patient safety debates, Dr. Pilcher explains that many medical schools are now beginning to teach something called metacognition.
This is described as a reflective approach to problem-solving that involves stepping back from the immediate problem to examine and reflect on the thinking process.
In other words, it’s “thinking about thinking.”
Some medical schools are already onboard with a shift in how med students ar trained. For example, Dr. Pat Croskerry is an Emergency Medicine physician, a patient safety expert and director of the critical thinking program at Dalhousie University Medical School in Halifax. He implemented at Dal the first undergraduate course in Canada about medical error in clinical decision-making, specifically around why and how physicians make diagnostic errors.
Meanwhile, Dr. Pilcher maintains that the busier the Emergency Department gets, the more critical thinking skills become vitally important to making accurate diagnoses.
(1) Acad Med. 2003 Aug;78(8):775-80.
(2) Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000; 342:1163-1170.
- Mandatory Reporting of Diagnostic Errors: “Not the Right Time?”
- Cardiac Gender Bias: We Need Less TALK and More WALK
- The Sad Reality of Women’s Heart Disease Hits Home
- Misdiagnosis: the Perils of “Unwarranted Certainty”
- How Can We Get Heart Patients Past the E.R. Gatekeepers?
- Heart Attack Misdiagnosis in Women
- The 18-Second Rule: How Doctors Missed Your Heart Attack Diagnosis
- Experts: Why So Wrong, So Often?