Physical examination is becoming a lost art and used less and less as technology driven medicine replaces clinical assessment. A recent article in the Washington Post highlighted the waning ability of doctors to use physical examination to make an accurate diagnosis. Over the past few decades, the physical diagnosis skills of physicians has decreased while the use of a dizzying array of sophisticated expensive tests has increased dramatically. Many healthcare organizations downplay the physical exam and think it superfluous compared to medical testing. Often, however, when technology is used without bedside skills, it takes the physician down a path where tests cause more tests to be ordered and, at the end after all the delay, the patient either sees a surgeon, a lawyer or an undertaker.
A misdiagnosis occurs in at least 1 out of every 20 patient encounters in doctors' offices, according to a study by researchers at the Houston Veterans Affairs Center for Innovation and Quality, Effectiveness and Safety and the Baylor College of Medicine. This translates into at least 12 million patients being misdiagnosed each year and, of these errors, at least half of these errors have the potential to cause severe harm. The rate of misdiagnosis malpractice in the primary care setting is higher than in any other area of medicine.
Primary Care Malpractice claims against primary care physicians are more difficult to defend and lead to a higher percentage of paid claims. A recent study in the Journal of the American Medical Association (JAMA) reported a study of 7224 malpractice claims over a 5 year period in Massachusetts, with 551 arising from primary outpatient care. The study found that although primary care claims accounted for only 7.7% of claims, they were significantly more likely to be settled (35% vs. 20%) and/or result in a plaintiff's verdict (1.6% vs. 0.9%).
Diagnostic errors are estimated to occur 10 to 15% of the times with the highest error rates in general care cases where patients are diagnostically undifferentiated, such as emergency rooms, family medicine and internal medicine. The article in the New England Journal of Medicine looked at why so many errors are made. In focused visual specialties such as radiology and pathology, error rates are much lower at 2%. Smart doctors make dumb mistakes when they fail to recognize that they are thinking on an intuitive level rather than on analytical level. That is, even doctors fall victim to cognitive bias which leads them to incorrect diagnoses. For instance, in 55% of fatal cases of pulmonary embolus, the diagnosis was completely missed. The brain processes information on two levels: an intuitive (Type 1) level and an analytical (Type 2) level. Intuitive Type 1 thinking is largely reflexive and autonomous often happening in the blink of an eye. These intuitive thinking patterns (heuristics) are either hard-wired into our brain or acquired through repeated experience. Trusting ones intuition is generally correct but not always. Unless physicians recognize when they are susceptible to Intuitive Type 1 errors, the misdiagnosis rate will not decrease.
Primary Care Malpractice Claims are mostly a result of missed diagnoses and medication errors, a recent study in the British Medical Journal reports. Thirty four studies performed in the United States, United Kingdom, Australia, Canada and France were reviewed. The most common cause of malpractice claims were missed or delayed diagnosis, accounting from 26% to 63% of all claims in all the studies. Death was the most frequent result of these misdiagnoses. Failing to diagnose cancer, myocardial infarction and meningitis were the most common errors. Medication errors were the second most frequent cause for malpractice claims, totaling between 5.6% and 20% depending on the study reviewed. Errors occurred with multi-provider care, with 43% of errors involving 2 or more clinicians and 16% involving 3 or more clinicians.
Medical diagnostic errors, such as the failure to diagnose a disease or condition or reaching an incorrect diagnosis, are a very serious type of medical malpractice. Diagnostic errors can lead to serious injuries and even death, and unfortunately this happens more than many New Jersey residents may be aware.