Diagnostic Error: The IOM Talks Trash (But Not Cash)

flying cadeuciiTo understand how a landmark new report on diagnostic error breaks the mold, go past the carefully crafted soundbite ­(“Most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences”) and rummage around the report’s interior.

You can’t get much more medical establishment than the Institute of Medicine (IOM), also called the National Academy of Medicine, author of the just-released Improving Diagnosis in Health Care. Yet in a chapter discussing the role played in diagnostic accuracy by clinician characteristics, there’s a shockingly forthright discussion of the perils of age and arrogance.

“As clinicians age, they tend to have more trouble considering alternatives and switching tasks during the diagnostic process,” the report says. Personality factors can cause errors, too: “Arrogance, for instance, may lead to clinician overconfidence.”

Wow. Sure, both those assertions are extensively footnoted and hedged later with talk of the importance of teams (see below). Still, given the source, this practically qualifies as “trash talking.”

Of course, those quotes didn’t make it into the press release. There, inflammatory language was deliberately avoided so as not to give opponents any easy targets. (Disclosure: I was an advocate of an IOM report on this topic while consulting to an organization that eventually helped fund it. After testifying at the first committee meeting, I had no subsequent involvement.)

Nonetheless, the 21-member committee’s diagnosis of the diagnostic error problem and its proposed steps to remedy it were thorough, evidence-based and relentlessly candid. The causes of diagnostic errors, the committee found, “include inadequate collaboration and communication among clinicians, patients, and their families; a health care work system ill-designed to support the diagnostic process; limited feedback to clinicians about the accuracy of diagnoses; and a culture that discourages transparency and disclosure of diagnostic errors, which impedes attempts to learn and improve.”

Noted Dr. John R. Ball, chair of the committee and former executive vice president of the American College of Physicians: “Diagnosis is a collective effort that often involves a team…Therefore, to make the changes necessary to reduce diagnostic errors in our health care system, we have to look more broadly at improving the entire process of how a diagnosis made.” Absent that change, errors will likely worsen as the care system grows ever more complex.

In short, this is a “call for major culture change,” said committee member Dr. Christine Cassel, chief executive of the National Quality Forum, in a webcast press conference. Doctors need to welcome “the patient questioning what you are thinking” and welcome feedback from colleagues who might discover a diagnosis was mistaken.

“It should be the norm that that doctor [who ascertains the correct diagnosis] picks up the phone and calls the other physicians to say what it was,” continued Cassel. “Now, it would be considered embarrassing and challenging the person’s professionalism to do that.”

Shades of the “end result idea” of Dr. Ernest Amory Codman from over 100 years ago!

In addition to endorsing training for clinicians to work collaboratively, the report stressed the importance of listening to patients and family members. That point was emphasized with a video of three patients telling personal stories.

“This report is about patients, for patients and it places patients at the very center of the diagnostic process,” said committee member Dr. Mark Graber, a senior scientist at RTI International and a founder of the Society to Improve Diagnosis in Medicine.

To that end, the IOM suggested a definition of diagnostic error that it called “patient-centered.” A diagnostic error is “the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient.” The committee also called for sharing of diagnostic information, including the clinician’s notes, with patients.

The report has a great deal more substance, including recommendations for malpractice litigation reform and payment reform to pay doctors fairly for the time required to converse carefully with patients. Right now, reimbursement rewards “doing” over “thinking.” Rummage around a bit more, however, and there’s another interesting thread.

The IOM report that launched the modern patient safety movement was released in late November, 1999. (Unfortunately, this IOM report on error begins with an error, saying that report was 15 years ago, using the official publication date rather than the actual one.) That 1999 report focused on “errors of execution;” that is, clinicians not providing the intended therapy. The estimate then that 44,000 to 98,000 Americans die each year from preventable medical errors in hospitals and another 1 million are injured grabbed headlines and prompted a push for change that persists to this day.

It has taken until now for a report examining diagnostic error (errors of intent). Yet in the interim, as this report states clearly, we have not had a standard definition of diagnostic error, reliable collection of data or agreement on what to do to reduce those errors. So what changed from 1999 until now?

A fact I only learned due to the personal involvement I noted above is that IOM studies don’t happen unless someone pays for them. The funding for this one was jump-started by the Cautious Patient Foundation, but the final bill of more than $1 million still required a laundry list of government and private funders to ante up contributions. Take away the donors and, “devastating consequences” of diagnostic errors or not, there’s no report on eliminating them.

To illustrate the point, go back to the 1999 IOM report death toll, which more recent estimates say could be as high as 400,000 a year. That number refers to preventable deaths just in hospitals. Even as care moves en masse to the outpatient arena, we have no standard definition, data collection or very much information at all on injuries and deaths from outpatient errors.

So while the IOM and its committee deserve plenty of praise for a job well done on diagnostic error analysis and prevention, let’s not forget the report no one has commissioned. How many more years must patients wait until someone pays the IOM to tackle outpatient error, as well?

Michael Millenson is a principal at Health Quality Advisors LLC.

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