Fatal Illness Misdiagnosed 20% of the Time

The New York Times reports today that “[s]tudies of autopsies have shown that doctors seriously misdiagnose fatal illnesses about 20 percent of the time. So millions of patients are being treated for the wrong disease. … With all the tools available to modern medicine — the blood tests and M.R.I.s and endoscopes — you might think that misdiagnosis has become a rare thing. But you would be wrong. …

“As shocking as that is, the more astonishing fact may be that the rate has not really changed since the 1930s. ‘No improvement!’ was how an article in the normally exclamation-free Journal of the American Medical Association summarized the situation.”

Why?:

“Under the current medical system, doctors, nurses, lab technicians and hospital executives are not actually paid to come up with the right diagnosis. They are paid to perform tests and to do surgery and to dispense drugs. … There is no [financial] bonus for curing someone and no penalty for failing, except when the mistakes rise to the level of malpractice. So even though doctors can have the best intentions, they have little economic incentive to spend time double-checking their instincts, and hospitals have little incentive to give them the tools to do so.” A neuro-ophthalmologist, responding to the article, posits that “doctors’ lack the time and intellectual curiosity … to use even the most rudimentary searching tools to aid them in diagnosis of a confusing patient” is the main reason for misdiagnosis. He goes on: “The core of the problem is that we are dumbing down medicine to a commodity.”

A simple database system that reminds doctors to “consider some unobvious possibilities that they may not have seen since medical school” might be part of a solution. It was developed by a father whose daughter was seriously misdiagnosed with chicken pox when she actually had a flesh-eating virus.

A few notes:

  • The JAMA article on which the NYT article is based seems to have been published in 1998 by George D. Lundberg, who recently said that the 3-page PDF article still reflects his views.
  • A 2003 JAMA article looking at autopsies as “a tool for quality management to analyze diagnostic discrepancies” found that “of 53 autopsy series identified, 42 reported major errors and 37 reported class I errors [class I errors are those that could have affected patient outcome] …. The median error rate was 23.5% … for major errors and 9.0% … for class I errors. … [W]e estimated that a contemporary US institution … could observe a major error rate from 8.4% to 24.4% and a class I error rate from 4.1% to 6.7%,” considerably less than 20%.
  • Two physicians responding to the current NYT article remind us that autopsies are performed less than 5% of the time. I’m guessing that autopsies are more likely to be performed in cases where cause of death is in doubt — in which case you might expect a fairly high rate of diagnosis discrepancy — and in cases where the deceased was not under a physician’s care — in which case you would expect no discrepancy of diagnosis, since there was none prior to the autopsy.
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