What can you do?
How can you contribute to decreasing diagnostic error rates? Expert opinion emphasizes: expand your knowledge; cultivate good clinical habits of mind, including expanding your knowledge and experience, self-care, humility, persistence, and the use of feedback; and utilize the use of metacognition—thinking about thinking, and work to improve the institutions within which you work.1
Expanding your knowledge
There is much for psychiatrists to learn in the realm of neuropsychiatric disease. Often patients with medical conditions will first present to psychiatrists thinking they have a psychological problem or a mental illness. Many will have common diseases: focal seizure disorders; neurodegenerative diseases in addition to Parkinson disease, such as Alzheimer disease, vascular dementia, or Lewy-body dementia; the long-term consequences of traumatic brain injury; autoimmune diseases such as multiple sclerosis; or sleep disorders. Some patients will have diseases that are less common: anti-N-methyl-D-aspartate receptor encephalitis, Wilson disease, Huntington disease, frontotemporal dementia. Familiarize yourself with the clinical presentations of these and other neuropsychiatric conditions.6 And remember to keep this question in the front of your mind: Could this patient have a medical condition that I am missing?
Diagnosing is a high-level creative process; as such it relies on reflective practices that allow time for you to think about your reactions to patients and about your diagnostic process.7 Even with a few moments of mentally stepping back to get perspective are important. In addition, actively employ strategies that force you to use the conscious, analytic system 2 cognition. Ask yourself, “What could this be?” Make a differential diagnosis list. Work against premature closure in the face of doubt and uncertainty. Remember that keeping a diagnosis “open” forces your “problem-solving mind” to keep working on what the diagnosis might be.7
Improving health care systems in support of diagnosing
Psychiatrists rely on hospital systems to support the diagnostic endeavor. Health care institutions may provide effective communication systems that allow collaboration with the patient and his or her family, health information technology, reliable laboratory services, access to library resources, expert second opinions, collaboration across disciplines, and specialties, and a culture that values reduction of diagnostic error rates while, at the same time, avoiding shaming and blaming.
Dr Schildkrout is Assistant Professor of Psychiatry, part time, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA. She is the author of two books: Unmasking Psychological Symptoms: How Therapists Can Learn to Recognize the Psychological Presentation of Medical Disorders and Masquerading Symptoms: Uncovering Physical Illnesses That Present as Psychological Problems.
1. Ball J, Balogh E, Miller BT, Eds. Improving Diagnosis in Health Care. Washington, DC: National Academies Press; 2015.
2. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78:75-780.
3. Croskerry P. Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv Health Sci Ed. 2009;14:27-35.
4. Yates BL, Koran LM. Epidemiology and recognition of neuropsychiatric disorders in mental health settings. Ovsiew F, Ed. Neuropsychiatry and Mental Health Services. Washington, DC: American Psychiatric Press; 1999: 23-67.
5. Koranyi EK. Morbidity and rate of undiagnosed physical illness in a psychiatric clinic population. Arch Gen Psychiatry. 1979;36:414.
6. Schildkrout B. Complexities of the diagnostic process. J Nervous Mental Dis. 2018;206:488-490.
7. Schildkrout B. Masquerading Symptoms: Uncovering Physical Illnesses That Present as Psychological Problems. New York: John Wiley & Sons; 2014.