Getting the right diagnosis is a key aspect of healthcare. As a registered nurse I have contributed to the formulation of patient diagnoses throughout my career. When I became a urology nurse practitioner in 2010, my scope of practice permitted me to autonomously and collaboratively provide patient-centred healthcare including the diagnosis and management of health conditions. I joined the “Diagnostic Error in Medicine Conference” to be updated on the latest insights in healthcare practices.
The Institute of Medicine’s 2015 report ‘Improving Diagnosis in Healthcare’ (1), states that “It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences”. This is a worrying statistic and thought-provoking for all of us involved in the formulation of diagnosis. With this is mind, I was keen to attend the 1st Australasian Diagnostic Error in Medicine Conference, held in Melbourne, Australia, from 23 to 25 May 2017.
A variety of disciplines (including nursing, medicine, pathology, radiology, education and research) were represented by the 220 participants who came from Japan, Singapore, United Sates, Australia and New Zealand. The presenters included world and local leaders in medical diagnosis, and patient advocates all sharing ideas and initiatives aimed at reducing diagnostic error. Right at the beginning I saw the positive energy of the participants, and in this column I would like to share some of the highlights of conference programme.
The conference theme was ‘Towards safer diagnosis- a team effort’. Day 1 started with a workshop entitled: “They got it wrong”: How patients and health professionals can make a difference through collaboration to obtain a positive outcome. This interactive session was co-hosted by a patient advocate and an emergency department physician. It started with a powerful video entitled “‘Jess’ Story” (2), a factual account of a young woman who visited specialists for over four years with a set of symptoms that no specialist was able to link with a specific diagnosis.
After a long period, Jess’ grandmother raised the possibility of Jess suffering from a rare inherited cardiac condition called Long QT syndrome, which she had seen on the internet. Jess’ neurologist stated that he did not believe this to be the case but reluctantly agreed to refer her to a cardiologist at the family’s request. He informed his colleague that he did not believe Jess had the condition, but the cardiologist went ahead and ordered a variety of diagnostic tests. The test results appear to have then been interpreted both incompletely, and with a closed mind, as the cardiologist also concluded that the young woman did not have Long QT Syndrome. He in fact informed Jess and her family that he had been unable to make a diagnosis. Jess died less than one year later, aged 17 years of age, of Long QT Syndrome.
The workshop attendees were told that Jess’ devastated mother channelled her grief into trying to understand what contributed to Jess’ missed diagnosis and becoming a patient safety advocate. She strongly believes that better communication between patients and health professionals can significantly improve the rate of diagnostic error and this premise was explored during the workshop through a series of doctor / patient vignettes performed by three professional actors.
The provocative scenarios stimulated discussion among the attendees about ways in which health professionals can begin to breakdown the embedded culture of our workplaces and empower patients, through our interactions, to speak up and effectively share their information and concerns. It was a thought-provoking dialogue that reminded us of our responsibility to create environments in which patients and their families can better understand the diagnostic process and feel more comfortable participating in the process.
Day 2 saw the start of the main conference programmeplenary sessions, case reviews, panel discussions, interactive workshops, oral abstracts and posters. The timetable included many thought-provoking sessions each aimed at improving our understanding of how diagnostic errors occur. Patient and family factors were discussed including the difficulties related to presentation with non-specific symptoms, challenges with health literacy, communication and cultural considerations. Clinician factors were explored; the risks associated with inadequate collaboration and communication with colleagues, the impact of varying levels of health professional knowledge and experience particularly after long hours, stress, fatigue and personal issues.
System factors were also found to be critical; time pressure and interruptions that may result in a shortened physical exam and a missed key finding, competing priorities that could lead a clinician to a diagnosis without adequate consideration of differentials, inadequate processes for ensuring follow-up of test results, especially after a patient has left the healthcare setting. Heads nodded around the auditorium- these were factors we all recognised from our daily practice. Collectively, they were labelled ‘contextual factors’, a term that became very familiar over the two-day programme.
One particularly interesting interactive symposium was entitled ‘Cognitive Biases: How Doctors think and de-biasing techniques’. A detailed case study of an emergency department presentation was used to identify and explore cognitive biases that impact on diagnostic error rates. These biases were many and varied but included premature closure (having one’s mind set on a diagnosis and not taking the time to explore differential diagnoses), confirmation bias (looking for evidence to support a preconceived opinion, rather than for information to prove oneself wrong), availability bias (formulating a diagnosis based on the fact that it comes to mind readily because it is common, easily remembered or recently encountered), anchoring bias (locking onto a diagnosis too early and failing to adjust to new information) and affective bias (the tendency to convince oneself that what you want to be true is true- most common if health professionals find themselves disliking a patient so they might write off a symptom as something minor rather than fully investigating it).
I observed the session participants to be particularly alert and focussed as these biases were discussed. Many could recall examples of witnessing such biases in action. The symposium leaders urged us to get to know our personal biases and our workplace environments as honestly as we could, in order to begin the process of finding ways to mitigate the effects of these biases on diagnostic reasoning. It was powerful stuff.
As the conveners wound up the conference they reiterated the expert committee’s conclusion that improving the diagnostic process is not only possible, but also represents a moral, professional and public health imperative. I certainly left the conference determined to look for ways to enhance work systems to support the diagnostic process in my work place. I imagine all other delegates were similarly motivated by the content of this really interesting inaugural conference.
(1) Improving Diagnosis in Healthcare (2015). Committee on Diagnostic Error in Healthcare. Editors: Erin P. Balogh, Bryan T. Miller and John R. Ball. The National Academies Press.
(2) Do No Harm: Jess’ Story. https://m.youtube.com (2012)
Sue Osborne, Urology Nurse, Auckland (NZ), firstname.lastname@example.org