Doctors working in hospital emergency departments face chaos, violence and high stress every day, and usually they get the diagnosis and treatment right. But, and it’s a big but, as often as one in seventeen ER visits ends with a misdiagnosis, which can have deadly consequences. Those medical misdiagnosis are newly estimated by Johns Hopkins medical school researchers as a significant peril for patients across the country.
Doctors in the too-often harried ER environs fail to correctly “identify serious medical conditions like stroke, sepsis and pneumonia,” leading to the deaths of as many as 250,000 patients each year, researchers at the Johns Hopkins University Evidence-based Practice Center found in their work for a federal health care oversight agency. The New York Times reported this of the work:
“The study, released [Dec. 15] by the Agency for Healthcare Research and Quality, estimates roughly 7.4 million people are inaccurately diagnosed of the 130 million annual visits to hospital emergency departments in the United States. Some 370,000 patients may suffer serious harm as a result. Researchers from Johns Hopkins University, under a contract with the agency, analyzed data from two decades’ worth of studies to quantify the rate of diagnostic errors in the emergency room and identify serious conditions where doctors are most likely to make a mistake. Many of the studies were based on incidents in European countries and Canada, leading some officials of U.S. medical organizations to criticize the researchers’ conclusions.
“While these errors remain relatively rare, they are most likely to occur when someone presents with symptoms that are not typical, like stroke patients complaining the room is spinning. A doctor may not immediately think that a young woman with shortness of breath is having a heart attack or that someone who has back pain could have a spinal abscess. ‘This is the elephant in the room no one is paying attention to,’ said Dr. David E. Newman-Toker, a neurologist at Johns Hopkins University and director of its Armstrong Institute Center for Diagnostic Excellence, and one of the study’s authors.”
The American College of Emergency Physicians has assailed the study, criticizing its data sources, methodology, conclusions, and tone. The organization, though, also joined other leading medical groups recently in urging the Biden Administration to take steps to remedy what the doctors and others have called unacceptable numbers of patients kept waiting for long, risky periods in ERs because hospitals cannot find space for their further care.
The Johns Hopkins researchers urged leaders in the U.S. health care system to dig into the training, support, and technology used by doctors, notably specialists in ER care, to see how misdiagnoses occur and how they might be slashed in frequency and severity. CNN reported this of the study and its findings that a handful of conditions most often were subject to ER problems:
“The top five conditions that were misdiagnosed were: stroke, myocardial infarction, aortic aneurysm/dissection, spinal cord compression/injury [and] venous thromboembolism. These five conditions accounted for 39% of all serious misdiagnosis-related harms. Stroke was missed 17% of the time, often because people reported symptoms of dizziness and vertigo. When they entered the ER, 40% of patients who had those two symptoms had their stroke missed initially. Nonspecific or atypical symptoms were the strongest factor resulting in misdiagnosis, the study found. Women and people of color had a 20% to 30% increase in risk of being misdiagnosed.”
More studies question doctors’ diagnoses
Indeed, even as the federal AHRQ study targeted ER doctors for lapses in women’s care, a separate Washington Post report detailed how doctors more generally dismiss or misdiagnose the pain and suffering of patients who are part of half the population. After describing some women’s ordeals in medical care, the news article reported:
“These are just some of the stories of women who say their pain and suffering has been dismissed or misdiagnosed by doctors. Although these are anecdotal reports, a number of studies support the claim that women in pain often are not taken as seriously as men. This year, the Journal of the American Heart Association reported that women who visited emergency departments with chest pain waited 29% longer than men to be evaluated for possible heart attacks. An analysis of 981 emergency room visits showed that women with acute abdominal pain were up to 25% less likely than their male counterparts to be treated with powerful opioid painkillers. Another study showed that middle-aged women with chest pain and other symptoms of heart disease were twice as likely to be diagnosed with a mental illness compared with men who had the same symptoms.
“Doubts about women’s pain can affect treatment for a wide range of health issues, including heart problems, stroke, reproductive health, chronic illnesses, pain, and physical pain, among other things, studies show. Research also suggests that women are more sensitive to pain than men and are more likely to express it, so their pain is often seen as an overreaction rather than a reality, said Roger Fillingim, director of the Pain Research and Intervention Center of Excellence at the University of Florida. Fillingim, who co-wrote a review article on sex differences in pain, said there are many possible explanations, including hormones, genetics and even social factors such as gender roles. Regardless, he said, ‘you treat the pain that the patient has, not the pain that you think the patient should have.’”
While ER specialists have attacked the latest study on misdiagnoses, this is far from the only research that has raised big concerns about doctors botching a fundamental, crucial aspect of medical care, the New York Times reported:
“Doctors say addressing diagnostic errors is challenging. While the National Academy of Medicine identified medical errors as a critical issue more than 20 years ago, most of the efforts to improve patient safety have focused on mistakes that are easier to identify, like when a patient gets the wrong medicine or develops an infection while in the hospital, said Dr. Robert Wachter, the chairman of medicine at the University of California, San Francisco, who had not seen the full report. ‘Diagnostic errors are a huge part of the problem,’ he said. The deaths that the report suggests occur every year ‘is a very concerning number,’ Dr. Wachter said. The study’s findings are higher than previous estimates, he noted.”
In my practice, I not only see the harms that patients suffer while seeking medical services, but also the clear benefits they can reap by staying healthy and far away from the U.S. health care system. It is, according to research conducted in pre-coronavirus pandemic times, fraught with not only misdiagnoses but also medical error and preventable hospital acquired illnesses and deaths.
Sure, working in the ER can be among the most demanding of all assignments that doctors take on. Treating patients who are grievously ill or injured and who may be in excruciating pain — a condition in itself that demands more remedies, as an expansive series in USA Today has found — can be a formidable task, especially given time and resource limits.
Alas, doctors are human, and research shows they are all too fallible. In pre-pandemic times, experts found that medical errors claimed the lives of roughly 685 Americans per day — more people than died of respiratory disease, accidents, stroke, and Alzheimer’s. That estimate came from researchers led by a professor of surgery at Johns Hopkins. Medical blunders have only worsened as the pandemic overwhelmed the U.S. health care system, reported Becker’s Hospital Review, an industry news outlet.
As for doctors’ role in determining the fundamental causes of what may be wrong with us, the Society to Improve Diagnosis in Medicine has provided disconcerting data. These researchers, health care providers, advocates, and others who seek to improve practices in the field to benefit patient safety, reported this earlier of misdiagnoses:
“Every nine minutes, someone in a U.S. hospital dies due to a medical diagnosis that was wrong or delayed. Roughly one in 10 patients with a serious disease is initially misdiagnosed. Diagnostic errors affect an estimated 12 million Americans each year and likely cause more harm to patients than all other medical errors combined. Misdiagnoses boost medical costs through unnecessary tests, malpractice claims, and costs of treating patients who were sicker than diagnosed or didn’t have the diagnosed condition.”
Patients and their loved ones, especially in medical emergencies, may not be well positioned to push their doctors for their best — insisting that they pay attention to the sick or injured individual before them, as well as answering careful, reasonable, but detailed and insistent questions about any tests, procedures, or diagnoses offered. We can’t put doctors and nurses on a pedestal, protecting them from providing patients their fundamental right to informed consent. This means they are told clearly and fully all the vital facts they need to make an intelligent decision about what treatments to have, where to get them, and from whom.
This also may mean that, conditions allowing, patients seeking out second or third opinions about their diagnoses and prospective treatment, notably if it is especially complex, uncertain, and costly. Good doctors understand patients’ desires to know as much as they can and to help determine the course of their medical treatment, including by consulting other physicians. As the Johns Hopkins study found, misdiagnoses posed an important but lesser peril in academic medical centers and teaching hospitals, likely because ER doctors in such facilities were more likely to consult with high-powered specialists who were their colleagues to tap their knowledge and experience about atypical cases.
Doctors make mistakes, and, by and large, patients and others in the public, as well as the law, recognizes that medical caregivers should not be unreasonably punished for error. But bad doctors, including those who repeatedly err in judgments on patients’ conditions and treatments, must be held accountable. Research shows that medical malpractice lawsuits provide one sound option to do so.
We have much work to do to improve diagnoses and to ensure that the medical care everyone in the richest nation in the world receives is safe, accessible, affordable, and excellent.