November / December 2012
The ‘Big Universe’ of Diagnostic Error
Patient safety advocates look forward to the day when principles they currently pursue as part of a directed agenda infuse the practice of medicine extensively, resulting in less need for advocacy, remedial training, and re-engineering because patient safety is baked into the culture of medicine.
At the 5th annual Diagnostic Error in Medicine (DEM) conference in early November, patient safety was still treated as advocacy, but the approach to solutions was so comprehensive and fundamental, it was possible to imagine that transformed future. In addition to communication, culture, and technology—subjects familiar to patient safety and quality improvement—DEM focused on ways to improve cognitive skills. Presenters also wrestled with the definition of diagnostic error, not just as terminology, but as a way to define the scope of problems and solutions.
Cognitive psychologist Glenn Regehr, PhD, described different kinds of experts and problem solvers, especially the “adaptive expert,” someone whose skills and training lead to more reliable diagnostic processes.
This adaptive expert is comfortable with ambiguity, with the idea that we don’t necessarily know the answer right now and is willing to dwell in the discomfort of not knowing the answer for periods of time, before moving forward in a meaningful way.… The adaptive expert understands the assumptive nature of facts.… Very often what we see in diagnostic errors is not just the fact that someone has made an error or misunderstood something at the beginning of the diagnostic process, but once they’ve made that decision, they hold onto it and assume it’s a fact and carry it forward through the rest of their thinking.
Regehr and others described ways that the patience, creativity, and confidence of adaptive expertise can be taught, as well as the all-too rare skill of “self-calibration”—knowing where our knowledge and expertise lie on the curve and when and how to consult colleagues and resources for help
Summing up the conference and suggesting goals for the future improvement, Johns Hopkins School of Medicine Assoc. Professor David Newman-Toker, MD, referred to the “big universe” of diagnostic error and urged us to think about this problem very broadly:
It’s not just the narrowly focused component where we know we made a mistake, we know it’s negligent and bad behavior, and we’re legally responsible in the sense of malpractice. There’s a must bigger world of reducible and discoverable harm that we should all be striving to fix.… We need to talk about overuse and underuse, over-diagnosis and under-diagnosis. What is good diagnosis? Accurate, timely, efficient, relevant, and appropriate. We can’t deny the issue of efficiency. It’s intrinsic to the problem of good diagnosis, and it’s also a public health priority. The rising cost of diagnosis is our obligation and it’s also our leverage.
All of this exploration and questioning happened with consumers and patient advocates fully engaged as attendees and presenters. As the convener of this conference, the newly formed Society to Improve Diagnosis in Medicine (www.improvediagnosis.org) deserves credit for creating a program and environment that was intellectually challenging, multidisciplinary, and inclusive.
Save the Date—Diagnostic Error in Medicine, September 22–25, 2013, Chicago, Illinois.