The Team Sport of Diagnosis: A Culture Shift Can Reduce Missed Diagnoses

flying cadeuciiEvery American will experience a missed or delayed diagnosis at some point in his or her lifetime. Saying that is not a scare tactic — it’s a reality, according to a 2015 National Academy of Medicine report titled “Improving Diagnosis in Healthcare.” Yet we have not made effective use of a simple solution: teamwork.

Among U.S. adults seeking outpatient care each year, 12 million are misdiagnosed. One in 20 hospital deaths results from a diagnostic error. Estimates suggest that costs of unnecessary tests, harms from misdiagnosis and legal payouts exceed $100 billion per year in the U.S. In short, inaccurate diagnoses are the most common, catastrophic and costly medical errors.

From a public health standpoint, we are in crisis.

Medicine is complex, and diagnosis is not an exact science, so we can’t always be right. But there is strong evidence that we can do a lot better than we do now. When we don’t follow best diagnostic practices, we tend to undertest patients who need it most, missing chances to provide prompt treatments for dangerous disorders.  

At the same time, we overtest patients who don’t need it, wasting precious diagnostic resources on those with benign conditions. With more accurate diagnostic assessments, we can fix both problems ― eliminating harms and reducing costs of care. For example, if we routinely followed evidence-based protocols for diagnosing dizziness in the ED, we could prevent 45,000 to 75,000 missed strokes each year and simultaneously save an estimated $1 billion per year.

The hospital and health care environments don’t help either. High patient volumes, time pressures, interruptions, distractions and failed communication can all lead to a missed or delayed diagnosis. Then there is the fact that we are human. At times, we make a mistake in clinical reasoning, such as when we are presented with a unique clinical problem that is outside of our clinical expertise.

Physicians are tasked with diagnosing the patient’s medical condition, but they are not the only ones who can ensure a correct diagnosis. Nurses, physical therapists, physician assistants and even family members may be the first to notice a change in the patient’s condition that indicates a wrong diagnosis. Sometimes nonphysicians have specialized knowledge critical to correct diagnosis. When armed with evidence-based diagnostic protocols and empowered to help physicians, these team members can ensure optimal diagnostic testing to maximize the odds of a correct diagnosis.

The National Academy of Medicine’s report offers an immediate suggestion to improve health care diagnosis today: teamwork. The same principle that rules sporting arenas and playgrounds across the world can reduce the number of diagnostic errors. The practice of medicine has traditionally been a lonely and risky competition. Doctors are used to calling the odds and making diagnoses without input from other members of the team, and nurses and physician assistants are taught not to question them. If a physician makes a mistake, there is a culture of blame, shame and fear of litigiousness, which makes it less likely that individuals will speak up or report a diagnostic error.

But better teamwork achieves much more than merely changing professional norms or local work culture. I have witnessed its benefit to patients.

In an endeavor to challenge health care cultural norms and combat diagnostic errors, I mentored a colleague from another medical center, a physical therapist with 24 years of experience specializing in vestibular and balance disorders. In a paper published online May 31 in Diagnosis, we highlight five case studies where the physical therapist’s expertise proved paramount in correcting a misdiagnosis in patients who showed up to the ED with dizziness. Her expertise in performing a physical therapy vestibular assessment resulted in better treatment, better patient satisfaction and quicker discharge.

Initially, her relationship with physicians was strained, and they didn’t value her input. She felt the pressure that many nonphysician health professionals feel in the face of doctors’ authority: a need to back down or tread lightly to avoid the perception of disrespect. Over time, however, her position improved, and she built trust with her physician colleagues who now value her input, routinely consider her diagnostic findings and even ask to learn her techniques.

Shaking up health care culture to improve patient care isn’t a new concept, and there is proof that it can be done. Peter Pronovost, M.D., Ph.D., director of the Johns Hopkins Armstrong Institute for Patient Safety and Quality and senior vice president for patient safety and quality at Johns Hopkins Medicine, created a comprehensive system that successfully reduced central line-associated bloodstream infections around the world. Empowering nurses to speak up was a critical yet simple component of the intervention. This system — now in place in 1,100 intensive care units across the nation and at hospitals in more than 20 countries — has reduced these infections by 40 percent.

While nurturing more effective relationships and communication between physicians and other members of the health care team won’t prevent all diagnostic errors, this shift is a simple and affordable step in the right direction. A less hierarchical approach to “team diagnosis” would empower nurses, physician assistants and physical therapists to speak up and develop more collaborative relationships with physicians, who in turn will begin to rely on their input to help prevent misdiagnosis.

To my physician colleagues, I’ll end with this simple advice: Pair up and offer mentorship to other members of your clinical team. Encourage them to pass along their expertise. Otherwise, we will miss a key opportunity to provide the best care to our patients, starting with an accurate diagnosis.

David E. Newman-Toker, M.D., Ph.D., is associate professor of neurology and director of the neuro-visual and vestibular division of the department of neurology at the Johns Hopkins University School of Medicine

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5 replies »

  1. You may be correct; can’t tell if you are talking about collaboration or diagnosis, though. Collaboration is fun and important, but not sure about diagnosis? I see teams make diagnosis mistakes routinely as that is my job; consult for diagnoses. Did second opinions change diagnosis outcomes? How about geriatric teams? Are there any clinical trials of team versus not? I and others were tested against QMR, Iliad, Isabel, etc in the 1990s as part of a “team” + computure study and the programs kept failing on the margin. What is the data? How would you study such a notion?

  2. Team-based care works well in anesthesiology, but someone still has to be captain of the team. Especially in the ICU setting, I see medicine by committee–lots of specialists, and no one who really takes a lead role in making sure all the different problems are treated in a way that looks at the whole patient. There’s a misplaced push toward “equality” in medicine: we’re all buddies, we’re all on a first-name basis, and God forbid anyone should be made to feel “devalued”. I believe in respect for all team members, but I also believe that the lead dog–surgeon, internist, intensivist, whatever–with the most credentials, the most experience, and the highest level of responsibility should be acknowledged as such. That being said, any leader is stupid who doesn’t listen to input from others before making key decisions.

  3. Well then the team can share the wealth in medical malpractice premiums, overhead in paying for PQRS, applying for patients preauthorizations/preapproval of procedures and drugs, and notifying the patient that the health plan Obummer gave them has a $6000 deductible, so all the tests are on your checkbook for the first $6K. If its a shared responsibility then it’s also a shared risk.
    I disagree with your premise. Too many cooks spoil the broth. What we need is a quarterback, and then a strong team to run on the quarterback’s direction and score the touchdown. The quarterbacks are not allowed to train, not allowed to run, not allowed to strategize or even talk to the patient in the 1o minute visit. We got problems….

  4. You guys, David Newman-Toker and Tom Emerick, have spoken the most important wisdom in medicine. Hooray!

    The wisdom of crowds. Get committees to review cases! Talk about patients to nurses and techs. Bring up cases in the coffee room. Call experts in other hospitals and medical schools. Confer. Holler. Yes yes.

  5. For complex cases, the ones most likely to be misdiagnosed, the best diagnoses occur when a team reviews the patient….the same for optimizing treatment plans.



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