Diagnostic errors more common, costly and harmful than treatment mistakes

This is the headline for an important review paper in BMJ in Quality and Safety. The paper is a must read for everyone. As noted by the authors, diagnostic errors are more complex and open up a huge can worms relative to surgical and medication errors. Given that the review only looks at the worst cases, the extent of the problem is probably severely underestimated. The results are even more striking when we consider the increase in defensive medicine. Psychology, in collaboration with medicine, has a huge role to play here.

The full paper can be found at: BMJ Qual Saf doi:10.1136/bmjqs-2012-001550

A short synopsis of the main results can be found at: http://m.hopkinsmedicine.org/news/media/releases/diagnostic_errors_more_common_costly_and_harmful_than_treatment_mistakes

Can we measure physician performance?

Can we measure individual physician performance? Social scientists have known for quite some time that performance evaluation can actually depress motivation. SO the question can actually become, not can we, but should we?  Cassell and Jain, in an interesting JAMA viewpoint paper [JAMA, June 27, 2012—Vol 307, No. 24] tackle the issue directly and present many compelling arguments as to why individual performance systems are likely to decrease intrinsic motivation and increase extrinsic motivation. The authors argue for more meaningful patient-centered goals that are clearly communicated. Ultimately, the authors recommend for more group/team based incentives. In my opinion, they are talking sense, and the paper is worth a read. Their paper is an interesting counter point to the idea of physicians as homo-economicus.  

Are GPs buckling under time pressure?

The need for physicians to see more people in less time is a stressor. The reduction in resources in healthcare means that such trends are set to continue and probably worsen. In a recent paper in BMJ Open (of which I’m a co-author) using an experimental approach, we found that under time pressure, adherence to guidelines concerning history taking and advice giving is compromised [BMJ Open 2013;3:e002700. doi:10.1136/bmjopen-2013-002700]. The research also found that GPs were less compliant with guidelines on giving advice on lifestyle, especially, concerning smoking habits. We should be mindful of how efficiency and effectiveness can travel in opposite directions. 

Are GPs buckling under time pressure?

The need for physicians to see more people in less time is a stressor. The reduction in resources in healthcare means that such trends are set to continue and probably worsen. In a recent paper in BMJ Open (of which I’m a co-author) using an experimental approach, we found that under time pressure, adherence to guidelines concerning history taking and advice giving is compromised [BMJ Open 2013;3:e002700. doi:10.1136/bmjopen-2013-002700]. The research also found that GPs were less compliant with guidelines on giving advice on lifestyle, especially, concerning smoking habits. We should be mindful of how efficiency and effectiveness can travel in opposite directions. 

Performing clinical tasks without proper training?

The first postgraduate year of medical training (currently termed as the ‘F1 year’ in the UK) is an important year in which junior doctors make the transition from medical student to trainee professional. A recent paper in BMJ Open [BMJ Open 2013;3:e002723. doi:10.1136/bmjopen-2013-002723] looks at the views of over 14,000 doctors (in 6 graduation years) with regard to this critical year of training. The most interesting result relates to the fact that approximately one in six F1 year doctors felt they had been required to perform clinical tasks for which they felt inadequately trained. It’s difficult to pinpoint what’s behind these views. The authors themselves provide alternative explanations. For example, they wonder whether the European WTD have resulted in lost opportunities for education and training. The research is an important insight into this critical year, and I wonder to what degree the culture of the organisation contributes to this phenomenon. It’s worthy of more in-depth investigation. 

Patient perspectives ARE in important! So, the evidence says...

Exploring the perspective of patients in how healthcare is delivered is desirable on ethical, utilitarian and empathetic grounds. Encouraging patient ownership of their medical journey leads to improved patient safety, clinical effectiveness, better adherence to medication and treatment. A recent systematic review of the area (Doyle, Lennox & Bell, 2013: doi:10.1136/bmjopen-2012- 001570) provides evidence. It concludes that patient experience is positively associated with clinical effectiveness and patient safety, and support the case for the inclusion of patient experience as one of the central pillars of quality in healthcare. Indeed, the authors of the review state that;  “Clinicians should resist sidelining patient experience measures as too subjective or mood-orientated, divorced from the ‘real’ clinical work of measuring and delivering patient safety and clinical effectiveness”.

Strong words, physicians take note....

What doctors won't do

There was an interesting article in UK Guardian Newspaper on Saturday http://www.guardian.co.uk/lifeandstyle/2013/jan/19/what-doctors-wont-do?INTCMP=SRCH
It's not a scientific article, but a collection of comments form British healthcare professionals about what medical treatments they would avoid or not do. It's quite a revealing and should make us reflect on why patients are reluctant and don't "adhere" in the way that are supposed too. Interestingly, and appropriately, there are contradictions between the respondents. Our healthcare professionals as patients is a subject that we need to know more about.