Primary care doctors can make the wrong call

(HealthDay)—In one case documented in a new study, an elderly patient was misdiagnosed with bronchitis but actually had full-blown pneumonia and ended up being admitted to the hospital.

Although that patient recovered, other symptoms that aren't properly diagnosed could be even more serious: numbness, tingling and dizziness that aren't recognized as the first signs of a stroke, for instance.

According to the new study, published online Feb. 25 in the journal JAMA Internal Medicine, primary care physicians can make diagnostic errors across a wide range of conditions, many of them common conditions such as urinary tract infections and anemia.

"There's a great heterogeneity of conditions [that are missed]," said study author Dr. Hardeep Singh.

Although much is known about medication errors and mistakes that occur in hospitals and other inpatient settings, less is known about mistakes that happen in doctors' offices or clinics, said Singh, chief of the Health Policy, Quality and Informatics Program at the Houston VA Health Services Research and Development Center of Excellence.

Similarly, while "high-profile" diagnostic mistakes—missed cancer that ends in unnecessary death, for example—often make the news, more mundane diagnostic errors can fly under the radar, he added.

In the study, Singh and his colleagues used electronic medical records to identify 190 cases of diagnostic errors that took place in a primary-care physician's office, either at a VA facility or in a private health care system. Sixty-eight of those were missed diagnoses, according to the study.

Diagnostic errors occurred across many common conditions, including pneumonia (6.7 percent of the cases), congestive heart failure (5.7 percent), kidney failure (5.3 percent) and urinary tract or kidney infection (4.8 percent). Cancer made up 5.3 percent of missed diagnoses, on a par with kidney failure.

Eighty percent of the errors were due to communication breakdowns between the patient and practitioner. This could have been failing to take a proper medical history or not performing a comprehensive physical exam. There also were problems with ordering and interpreting tests and follow-up care.

More than 40 percent of the cases studied involved more than one of these factors.

Although all the cases reviewed in this study involved patients coming back for—and receiving—follow-up care, the cases did have the potential for "moderate to severe harm," the authors said.

It's not clear if these findings would extrapolate into other primary care settings, especially ones that aren't part of a larger health care network, the authors said. (Even in this study, the authors found different patterns in the VA network versus the private system.)

The authors did not say what proportion of total diagnoses were in error, said Dr. Doug Campos-Outcalt, chairman of family medicine at the University of Arizona College of Medicine, in Phoenix.

But few people would deny that primary-care physicians are overworked, underpaid and stressed for time, so fixing such errors is likely to be a long-term process.

Having electronic medical records systems and medical "homes," a concept that has been developed where patients can get many of their health care needs met in one place, may reduce diagnostic errors, but how common either will eventually become is still unclear, Singh said.

Giving doctors more support from a team of nurses and other health care professionals, along with complete electronic medical health records on patients, also may help, Singh said.

Patients can also play a role.

"If you have five symptoms, you need to be patient so you can tell the doctor what's going on properly," Singh said. "Getting the story right is important. Following through with instructions is important."

Campos-Outcalt said he is "convinced that continuity of care with the same physician or team can prevent many of these errors. We tend to get lost when there are too many referrals. Continuity of care is a strong ally. We can get to know the patients and know the symptoms."

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