Sept. 11, 2019 — Nearly 17% of doctors estimated in a Medscape poll that they make diagnostic errors every day.
That number varied by specialty. Pediatricians were less likely to say they made errors in their diagnoses every day (11%), and emergency medicine doctors were more likely, at 26%. In between were doctors in family medicine (18%), general practice (22%), and internal medicine (15%).
Nurses, advanced practice registered nurses, and physician assistants answered similarly: In all three categories, 17% said they estimated they made diagnostic errors daily.
The poll, posted June 26, comes after Medscape reported results from a study in the Journal of General Internal Medicine that suggested doctors tend to underestimate how often they make diagnostic errors.
Those responding to the poll included 633 doctors and 118 nurse practitioners, for a total of 751.
Researchers at the Johns Hopkins University School of Medicine in Baltimore conducted a survey of doctors at nine Connecticut internal medicine training programs to assess thoughts about diagnostic uncertainty and error.
Most believed diagnostic errors to be uncommon (once a month or less), even though half of them said they felt diagnostic uncertainty every day. Previously published figures estimate that diagnostic errors happen in 10% to 15% of all patient encounters.
A registered nurse wrote in the comments on the Medscape poll that it’s important to make a distinction between incorrect diagnoses and uncertainty. “The latter is part of the basis for a referral to a specialist,” he noted.
Poll results showed that nurse practitioners and physician assistants reported slightly higher rates of daily diagnostic uncertainty than did doctors.
Uncertainty rates were similar for male and female doctors.
Reasons for Errors
Doctors, nurse practitioners, and physician assistants agreed on the top three reasons diagnostic errors happen. One was “lack of feedback on diagnostic accuracy” (38% of doctors and 44% of nurse practitioners/physician assistants listed that as a top reason). Another was time constraints, listed by 37% of doctors and 47% of nurse practitioners and physician assistants. Rounding out the top three was “a culture that discourages disclosure or errors” (27% of doctors; 33% of nurse practitioners/physician assistants).
Emergency medicine doctors were more likely than doctors in general (76% vs. 52%) and nurse practitioners/physician assistants (64%) to say they had diagnostic uncertainty daily.
An emergency medicine doctors who commented on the poll explained the uncertainty in his specialty: “I dare say we in EM cannot give a definitive diagnosis in the majority of undifferentiated presentations we see,” he said.
“Our primary objective is to perform a ‘medical screening exam’ to rule out to a reasonable degree of certainty that an emergency medical condition is not the cause of the patient’s acute chest pain, abdominal pain, headache, etc. We focus on making the safest disposition through evidence-based risk stratification processes. It is a system that works fairly well sorting the emergent from the non-urgent,” he said. “We strive to be honest in that we often don’t know the definitive cause of the low-risk chest pain, headache, abdominal pain, etc. Often our most important intervention is simply reassurance that it is safe to follow up with the specialist for further testing.”
Asked at what point they were uncertain about their diagnoses, the greatest percentages of providers (70% of doctors and 76% of nurse practitioners and physician assistants) answered that it was when making the actual diagnosis. The second most frequent time for uncertainty was when deciding what tests to order (34% for doctors and 50% for nurse practitioners/physician assistants).
An internist said one cause of uncertainty in diagnosis was not listed as an option in the poll — “the inherent nature of biological systems.” Not all symptoms or conditions can be diagnosed, at least in a timely manner, he said.
“We are not ‘omnipotent,’ ” he wrote. “We do not understand in totality human physiology/pathology. Just because a diagnostic ‘label’ cannot be applied to a patient within a certain time, or that a reasonable diagnosis was applied that turns out to be ‘incorrect,’ does not mean an ‘error’ occurred.”
A veterinarian who responded to the poll said that artificial intelligence (AI) may one day bridge the gaps in diagnosis for health care providers of all kinds.
“There are so many variables and possibilities, I’m convinced, even for seasoned practitioners, our salvation will be AI, and we will collaborate with our computerized ‘partners,’ ” he said.