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Diagnostic Excellence
April 11, 2022

Aligning Incentives for Improving Diagnostic Excellence

Author Affiliations
  • 1USC Schaeffer Center, University of Southern California, Los Angeles
  • 2Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
JAMA. 2022;327(16):1543-1544. doi:10.1001/jama.2022.4594

Diagnostic excellence is a priority of both patients and individual clinicians, yet does not seem to be afforded the same attention by health care systems. Autopsy data from 2 Swedish hospitals revealed that 30% of 2410 cases had clinically significant undiagnosed diseases.1 A review of methods used to estimate the rate of diagnostic error suggested that diagnostic errors are more common than medication errors.2 Even for conditions that are considered “easy” to detect, such as hypertension, 1 estimate suggested that 10% of US adults may have high blood pressure that is undiagnosed.3 Failure to make diagnoses expeditiously leads to prolonged uncertainty and may result in costly unnecessary tests and procedures, delayed treatment, and increased risk of morbidity and mortality. If diagnoses are forgone in favor of empirical treatment, patients may receive ineffective or potentially harmful treatments. Given this, a key question is why physicians would take shortcuts on diagnostic workups and rely on guesses and intuition when initiating treatments when it is possible to make accurate diagnoses and deliver evidence-based care.

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2 Comments for this article
Dealing Diagnostic uncertainty
Amit Desai, DO | Hospital
The article conflates issues of diagnostic errors, medical overuse due to fee-for-service billing, and diagnostic uncertainty in clinical decision making.

Inability to make a diagnosis due to limits of medical knowledge might be as frequent as being able to make a correct diagnosis. The example of undiagnosed hypertension and other cardiovascular risk factors in the general population is a simplification of the problem.

There needs to be greater acceptance of diagnostic uncertainty rather than penalizing systems and physicians for not being able to make a clear or timely diagnosis. Inadequate physician training in dealing with
clinical uncertainty, and failure to openly acknowledge limits of science without being shamed, both might lead to extensive testing rather than the other way around. Teaching physicians and patients ways to deal with uncertainty is an urgent priority.

An issue separate from diagnostic errors due to competency is errors due to heuristics-based diagnostic reasoning, with infrequent use of Bayesian probabilistic reasoning.
From a Discouraged General Internist
Caroline Poplin, JD, MD | Arlington Free Clinic, Arlington VA
Comments from a discouraged general internist:

Unless I missed something this piece never mentions patients. Are their preferences, not to mention their fear of cost, irrelevant?

Also, guidelines are supposed to be recommendations, not rules: Strong recommendations are Class 1. What should we do about class 2A (moderate strength) or Class 2B (weak)? Maybe, since AI can incorporate more considerations than any single human, and automatically include every new development instantaneously, this will no longer be a problem.

Somehow the authors challenge heuristics (which practicing doctors often employ because of limited time or resources), insisting instead
on expensive new gold-standard tests, such as genetic testing for all breast and ovarian cancer. But who will pay for these, since the authors disfavor fee-for-service?

The authors seem to assume that they themselves don’t make diagnostic mistakes, or order any “extra” tests.

It seems the only way an intelligent physician—but not a genius--can handle this is to become a narrow sub-specialist, with an academic position that allows them to see a few patients, but enough time to keep up with every new development in their field. Or to become a venture capitalist or a senior government official.

I have never met a physician who was not trying to make a correct diagnosis, every time. We don't need more "incentives", financial or otherwise. Help us, don't punish us.