[NB: The following appeared on the opinions pages of the Philippine Daily Inquirer Vol. 28 No. 137 April 26, 2013 issue, the online version can be found here. It was written by Dr. Leonardo L. Leonidas who retired in 2008 as assistant clinical professor in pediatrics from Boston’s Tufts University School of Medicine, where he was recognized with a Distinguished Career Teaching Award in 2009. He is a 1986 graduate of the UP College of Medicine. All copyrights remain with their respective authors and the Philippine Daily Inquirer]
What will you do if one in a hundred plane flights crashes, resulting in injuries? Will you still fly? Or what if one in a hundred bank transactions results in an error in your balance? Will you still trust your bank? In these two instances, the error rate is much less than 1 percent and is fortunately hypothetical. And the chance of these happening is slim because of the technology we have today.
However, if I tell you that 5 to 15 percent of physicians’ diagnoses, whether they are made in hospital emergency rooms or medical offices, are wrong, will you believe it?
In a survey conducted by a diagnostic decision-support software company, it was found that 35 percent of adults in the United States had experienced a medical mistake in the past five years involving themselves, their family, or friends. Moreover, half of the mistakes were attributed to diagnostic errors. Fifty-five percent of the respondents listed misdiagnosis as their greatest concern when seeing a physician outside the hospital. At the same time, 23 percent of them cited misdiagnosis as the error that concerns them most in a hospital.
In the Harvard Medical Practice Study of 30,195 hospital records, diagnostic errors were blamed for 17 percent of adverse events. In another study of 15,000 patient records from Colorado and Utah, researchers found that diagnostic errors contributed to 6.9 percent of the adverse events.
Goldman and colleagues studied 100 randomly selected autopsies from the years 1960, 1970, and 1980 at one institution in Boston. They found that the rate of misdiagnosis was consistent over time.
Alan Greenspan, in his testimony in the US Congress, used “Credit Crisis Tsunami” as a description of what is going on in our economy today. Similarly, in medicine we are also having a tsunami, but a silent one. And this has been going on for decades.
About 12 years ago while visiting Manila, my wife experienced pain in her right big toe. When we returned to our home in Bangor, Maine, in the United States, her joint pains became recurrent. Then, after several years of seeing four board-certified physicians, she was ultimately diagnosed, with the use of MRI, to have a ruptured meniscus in her right knee. She was then scheduled for knee surgery.
Weeks before her scheduled surgery, our son, who was then in his third year in medical school, came to visit. Because I was not comfortable with the diagnosis of ruptured meniscus, I discussed his mom’s case with him, asking him: “Len, with your background on photography, how can an MRI be false positive?”
Our son explained to me the physics of MRI and some principles in perception. He told me: “Dad, if there is something in front of the meniscus distorting the magnetic rays from the MRI, the radiologist will not see a clear outline of the meniscus.” So I asked him what could actually do that. He said that for one, crystals in the knee could cause a false positive reading. I asked what could account for those crystals, and he replied: “Gout.”
With that information, one week before the scheduled surgery, we made an appointment with a rheumatologist. He took fluid from my wife’s right knee and big toe, and within 10 minutes he had a diagnosis—gout. So I cancelled the surgery, and my wife is now better.
After 37 years of practice in pediatrics and studying this topic, I think that like our financial tsunami of 2008, there are many contributing factors. The first is the way we educate physicians. The model of medical education is still the same today as it was 50 years ago. Our diagnostic tool is dependent mostly on our “unaided” brain. Compared to the pilots who use technology in every aspect of their flights, physicians do not. Many diagnostic errors are the result of poor history-taking during the first visit. Many physicians simply do not have enough time to ask the right questions, or they forget to.
The second is that the medical community has failed to recognize that diagnostic error is contributing to the high cost of care and death. In the yearly medical conferences I have attended, none was devoted to diagnostic errors. At the same time, most medical schools have not included any course on diagnostic errors and how to do outcome studies of their patients. This will change soon because the new dean of the University of the Philippines’ College of Medicine is proposing “Safety in Medicine” as part of the curriculum.
Lastly, the manner by which physicians keep medical records in our hospitals and offices in the Philippines is still mostly in handwritten and dictated notes. We should convert to full, secure relational-based electronic medical records that physicians can do outcome studies with in just a few clicks of the mouse. And the records can be securely accessed by patients at any time.
Medical care is a complicated affair, and the communication between physicians and specialists, physicians and their patients are not yet efficient. An intelligent electronic medical record is the first step to reducing diagnostic errors.