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'Study' on errors has its own flaws.

It's hard to know where to begin in dissecting this "study" ("Diagnostic Errors by Internists Often Go Unrecognized," Aug. 15, 2007, p. 1).

One hundred errors from five hospitals over 5 years? What was the total number of patients treated by internists over that time at those hospitals? Internists, like other human beings, are not perfect! That bears repeating: Internists are not perfect.

Given the researchers' benefit of residing in the heights of the ivory tower, flinging criticisms on the heads of those below like thunderbolts from Zeus (and doing as much benefit), and having the accuracy of hindsight, what is the news-worthiness of such an article? We can agree that one error is one too many. What was the definition of a delay in diagnosis? One hour? Twelve hours? Twenty-four?

The interest and the danger in internal medicine reside in the fact that most patients are not sitting in the exam room with a neat bow on the head and a blindingly obvious diagnosis. The chest pain may be a cardiac event but could also be costochondritis, or chest wall pain from repeated bouts of coughing. Or it could be gastrointestinal in origin. Once a patient arrives at the subspecialist, most of the diagnosing has been done by the referring internist--and probably more cost effectively. Were a patient to self-refer to a cardiologist with a complaint of dizziness, the workup would include the usual: echo, Holter stress test, TEE, cath, etc., only for the patient to be told that the dizziness is not of cardiac origin. The subspecialist would then refer the patient to the primary care provider (not doctor, mind you).

This "study" is nothing more than grist for the plaintiffs' bar mill.

Paul Sovran, M.D.

Kissimmee, Fla.

Dr. Mark Graber replies:

I sympathize with Dr. Sovran's sentiments, because I, too, take care of patients in clinics and on the wards and I struggle with all the uncertainties and challenges that our patients present us in terms of accurate and timely diagnosis. Very few conditions present in "textbook" fashion, and even if they do, we can err!

But to become complacent about this, is not consistent with the core values of being an internist. The point of our article and the work that was referenced (Arch. Intern. Med. 2005;165:1493-9) is that diagnostic error is not just a fact of life that we have to accept. These errors have causes, and we are hopeful that beginning to identify and study these will lead the way to fewer errors in the future. It would be premature to suggest what the best solutions will be, but there is reason for optimism in terms of both the system-related as well as the cognitive causes of error.

Many, or at least some, of the system-related root causes can be addressed through things such as decision support tools, communication tools, and enhanced access to expertise when it's needed. The cognitive causes of error will be a more interesting challenge, but insisting on early and reliable follow-up of new patient problems, encouraging reflective practice, and improving feedback on patient outcomes are simple ideas that have potential merit.

All of this is contingent on engaging internists in trying to understand and reduce our error rate. It's absolutely true that anyone involved in direct patient care will inevitably make mistakes, but we shouldn't accept the current error rate, however low or high it may be, as the norm.


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Title Annotation:LETTERS
Publication:Internal Medicine News
Article Type:Letter to the editor
Date:Oct 1, 2007
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