In September of 2015, the Institute of Medicine (IOM) issued an important report about diagnostic errors in health care—Improving Diagnosis in Health Care.1 This landmark document emphasizes the high incidence of missed and delayed diagnoses in every field of medicine: “. . . the best estimates indicate that all of us will likely experience a meaningful diagnostic error in our lifetime.”1 After a brief description of the scope of the IOM report, this article summarizes content that is especially relevant for psychiatrists.
Diagnostic error is defined in the IOM report as “the failure to (a) establish an accurate and timely explanation of the patient’s health problems or (b) communicate that explanation to the patient.”1 In the US, diagnostic error is the major source of paid medical malpractice claims and contributes to 10% of deaths, according to postmortem examination research. In addition to summarizing what is known about the diagnostic process and diagnostic errors, the IOM report makes numerous recommendations and emphasizes that much can be done to improve the current state of affairs.
The report is scientific and far-reaching in both scope and method. Yet it always keeps the human element front and center, including the powerful cognitive and psychological factors that have an impact on the diagnostic process. It explores the multifarious contributions to the problem of missed diagnoses. For example, diseases may be atypical in their presentation, rare, or as yet unknown. Patients and family members may be poor communicators, not understand the diagnostic process, or behave in ways that are off-putting. Doctors and other health care professionals may be busy, fatigued, stressed, lacking in certain competencies, inexperienced, or imperfect in their reasoning. System issues may range widely, including factors such as an unsatisfactory physical environment, problems with the availability of consultants, inadequate laboratory and imaging resources, burdensome technology that does not effectively support the diagnostic process, a workplace structure that undermines teamwork, a culture that discourages acknowledging and learning from mistakes, inadequate management of team responsibilities and work flow, ineffective feedback to physicians, or poor follow-up communication with patients.
Dr Schildkrout is Assistant Professor of Psychiatry (PT) at Harvard Medical School, Beth Israel Deaconess Medical Center in Boston and the author of Masquerading Symptoms and Unmasking Psychological Symptoms. She reports no conflicts of interest concerning the subject matter of this article.
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