18 Sep Doctor Behind ‘House’ Puzzlers Says Bringing Errors Out Into Open Helps Us Learn
“Why is this patient empowerment thing so difficult?” That’s a question moderator John Hockenberry asked kicking off Monday’s sessions at the Mayo Clinic Center for Innovation’s Transform 2014. He followed with the question he described as the big idea of Transform, “Who is responsible for health in the community?” The symposium, designed to highlight thought-provoking, inspiring ideas, wrapped on Sept. 9 this year. You can view the updates for Transform 2015 on the website.
The first session on Monday morning was designed to get to the heart of Hockenberry’s questions, addressing the idea that if the “responsibility for health care is shifting to individuals … do we really understand what people need?”
One of the speakers hoping to shed some light was Lisa Sanders, M.D., a clinician-educator at the Yale School of Medicine who writes the "Diagnosis" column for the New York Times Magazine and the "Think Like a Doctor" column for the New York Times blog, "The Well." She also was a technical adviser to the television show “House.”
Dr. Sanders’ talk, which explored the idea of improving diagnostic skills by learning from our mistakes, started with the story of one of her patients and what she described as an error on her part. Dr. Sanders says a longtime patient who was fighting emphysema called to say she was having a flare-up and needed help. The patient described her symptoms, which fit with her self-diagnosis, but refused to come in to see Dr. Sanders, saying she was too sick to go out in bad winter weather. The patient asked if Dr. Sanders could just prescribe the medications she had with previous flare-ups. Dr. Sanders consented, but when she called a few days later to follow up, the patient said she’d been getting worse.
When Dr. Sanders insisted she go to the hospital, the patient again refused, saying she wanted to be at home with her bird and cat. Unable to convince her patient, Dr. Sanders packed up her bag and went to visit the patient at home during her lunch hour. Once there, she recognized that the patient’s symptoms were from heart failure rather than emphysema, and she told the patient this could be fixed with a pacemaker. Armed with the new information, she finally persuaded the patient to go to the hospital to be treated.
In retrospect, Dr. Sanders says, although she was operating on the information available to her, she considered that a diagnostic error on her part. The way doctors tend to look at errors, she says, often keeps them from learning and improving their diagnostic skills. That’s beginning to change. Diagnostic error is defined as “a diagnosis that’s unintentionally delayed, wrong or missed.” Dr. Sanders argues that it’s also the way doctors learn. “We start with the most common things and move out to less likely diagnoses,” she says.
“An error is not a mistake. Until we accept that, it’s going to be very hard for us to learn from our diagnostic errors.” – Dr. Lisa Sanders
“Diagnosis is an extremely uncertain art. We’re taking our best shot. It’s a very uncertain practice.” Continuing on that theme, she says, “An error is not a mistake. Until we accept that, it’s going to be very hard for us to learn from our diagnostic errors.”
And while diagnostic errors may seem more common for rare conditions, it’s actually more common conditions that make up the majority of diagnostic errors. The top four missed diagnoses, according to a recent study, are acute renal failure, pneumonia, cancer and congestive heart failure.
“It’s just over the past few years that people have begun to get together to talk about errors and learn from them,” she says, adding that while there may be disagreement on the definition of an error, “We can all agree that it would be better if there were fewer of them.”
Dr. Sanders offered a few ideas on how to reduce diagnostic errors.
- Teach it — teach doctors to become better diagnosticians. “At Yale, just a couple of weeks into their education, we send medical students into a room with dummies, and we give them a case,” she says. “They have no medical training, and we ask them to try to puzzle through a difficult case.” Then they use that experience, whether successful or not, to teach the students about diagnosis.
- Feedback is essential. Doctors don’t typically get feedback, Dr. Sanders says. “When we see a patient, we listen to them, we diagnose them, we treat them, and we send them out and think it’s another victory for medicine. We don’t know what happens after that.” That can lead to a false sense of success, noting that 80 percent of drivers think they’re excellent drivers because they don’t hear (or see) the feedback that other drivers might be giving them. Systems are being set up to try and bring back data to the doctor, however, she says.
- Time matters. “When I was coming here, the question was, ‘Do we know what our patients need?’” Dr. Sanders says. Time with the patient is key to answering that question. The average medical appointment is 10 to 15 minutes, she says, and the rate of errors increases at less than 16 minutes. At Mayo Clinic, by contrast, she says, at an initial appointment, the patient has 90 minutes with the doctor.
- Where health care is delivered matters. “Why do the sick have to come to doctor?” Dr. Sanders asked. “We don’t have systems to deliver health care to people in their homes. Sick people shouldn’t be denied care because they can’t travel.”
- Teamwork matters. Dr. Sanders talked about the importance of teamwork not just among members of the health care team, but between the health care team and the patient. “They must work together as a team” to be successful, she says. “Nobody’s voice trumps the other.”
Dr. Sanders closed by saying that “making the right diagnosis as quickly and efficient as possible is the most cost effective care we can deliver,” and suggesting that examining errors can help. “Let us stop trying to bury our mistakes,” she says. “Let’s bring them out in the open and learn from them, so that everyone can get the care they need.”