All entries for Monday 27 February 2006
February 27, 2006
The NYT writes about how rates of misdiagnosis in US hospitals haven’t fallen over time despite great improvements in technology.
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. Studies 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.
How can this be happening? And how is it not a source of national outrage?A BIG part of the answer is that all of the other medical progress we have made has distracted us from the misdiagnosis crisis. Any number of diseases that were death sentences just 50 years ago — like childhood leukemia — are often manageable today, thanks to good work done by people like Dr. Bergsagel. The brightly painted pediatric clinic where he practices is a pretty inspiring place on most days, because it's just a detour on the way toward a long, healthy life for four out of five leukemia patients who come here.
But we still could be doing a lot better. 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.
My knowledge of medicine is limited to Scrubs, Grey’s Anatomy & House M.D. In any case, the real world must deal with which medical practitioners who are stressed, limited by the finances of hospitals and limited in the time they can devote to any one case. This necessitates shortcuts and thus errors. Consistency in errors doesn’t in itself signal a crisis. However, the article’s claim that doctors should receive greater feedback seems fair. That feedback may be produced internally (e.g. internal audits), or via the market (e.g. payment by results). Without feedback, incentives to learn and correct mistakes are limited. Autopsies are a means of generating feedback; a means of comparing causes of death to prior diagnoses. This article states that autopsy rates in the US need to be increased significantly so as to uncover systematic errors. I don't know details, but this piece from the president of the Royal College of Pathologists suggests the UK isn't too dissimilar.
Despite the obvious value of autopsies, the proportion of deaths (disregarding those investigated at the request of a coroner) subjected to this highly informative medical investigation has fallen steadily during the last few decades. Now, even in UK teaching hospitals, the autopsy rate is usually below five per cent. This has serious implications for clinical governance and audit, for the detection of unexpected adverse effects of medical interventions, and for undergraduate and postgraduate medical education. Regrettably, many doctors are now graduating from UK medical schools without ever having witnessed an autopsy.