Improving diagnostic performance: some unrecognized obstacles

Abstract

Abstract:The growing interest and activity focused on improving diagnostic performance is a needed and welcomed change to which the new journal, Diagnosis, nicely attests. While the importance of raising awareness and building the evidence-base needs to be underscored, these efforts by themselves do not translate directly into improvements for patients. The complex and multifaceted nature of diagnostic work is becoming better understood, yet many of the obstacles seem to operate beneath the surface where the press of daily practice allows many of the untoward issues to be tacitly ignored. The purpose of the paper is to shine a light on some of these less reco gnized issues or obstacles. Among the issues addressed is whether use of the error term as in diagnostic error or medical error is serving us well in gaining of better understanding of diagnostic work, the lack of sensible feedback mechanisms that deny diagnosticians and their organizations the opportunity to learn something about their diagnostic performances, the double-edge nature of feedback, the obstacle of frame blindness, and the need for innovative empirical testing of promising ideas for improving diagnostic performance such as taking advantage of diagnostic simulation techniques that are inexpensive to generate and do not put patients at risk.

Challenges and opportunities from the Agency for Healthcare Research and Quality (AHRQ) research summit on improving diagnosis: a proceedings review

“…Does being told "let us worry about the diagnosis" by clinicians inhibit patient involvement? Second, diagnosis, to a large extent, has been described as an open-loop system where there is no self-correcting feedback mechanism, as in more reliable systems [44,45]. In the absence of information about patient outcomes and a measurement scheme for making sense of them, clinicians are denied the opportunity for learning something about their diagnostic performance.…”

“…And fourth, has enough consideration been given to the tenets of learning organizations? Those diagnostic specialties and organizations that recognize they are involved in a generative process; that is, trying to learn how to implement evidence-based information that research produces, and formulating new ways of perceiving and thinking about diagnostic challenges to more proactively shape them, deserve to be known as learning organizations [45,50]. Learning organizations are those that take learning-to-learn seriously, empower individuals to transcend self-interests for higher collective goals, and continually expand their capacity to generate safe and satisfying outcomes for their patients and themselves.…”

Use of an Expedited Review Tool to Screen for Prior Diagnostic Error in Emergency Department Patients

“…Too, we were dependent on information and reasoning documented in the EHR, therefore falsely flagging instances where a clinician considered, but did not document, the ultimate diagnosis. Conversely, there may be missed diagnoses still missed on repeat presentations.We also recognize that rating a missed or delayed diagnosis involves subjective judgment, and there are appreciable concerns that reviewers will consistently overestimate the degree to which a diagnosis was truly missed given the constraints of the initial interaction [8,20]. We attempted to control for this by using explicit criteria as well as having a second reviewer for all cases with any possibility of missed diagnoses, plus a random sample of the negative subset of cases.…”