Feedback Could Help Hospitalists Improve Diagnosis

Marcia Frellick

March 10, 2016

SAN DIEGO — Clinicians with sharp diagnostic skills know whether an original diagnosis has changed, and why.

Too often, hospitalists don't hear about changes after the patient leaves their care, said Andrew Olson, MD, from the University of Minnesota Masonic Children's Hospital in Minneapolis.

Athletes get better by analyzing their statistics, and doctors should have the same opportunity, he said here at the Society of Hospital Medicine 2016 Annual Meeting.

"You can know your batting average on Tuesday afternoons against left-handed pitchers when the temperature is below 70 degrees. But I wonder how good I am at diagnosing pneumonia. I don't know," he said.

Information such as the time of day a diagnosis was made and what preceded it could help hospitalists analyze what is affecting the way they diagnose. "I think we should know how good we are," Dr Olson explained.

That is hard to see without outside perspective, said Benji Mathews, MD, from Regions Hospital in St. Paul, Minnesota, who presented with Dr Olson. He suggested peer coaching sessions, where members of the medical team discuss how a diagnosis was made and why it changed. "They can help you with your blind spots," he said.

I wonder how good I am at diagnosing pneumonia. I don't know.

A peer-review process has been instituted at the University of Minnesota, Dr Olson reported. At handoff, doctors complete a form that asks whether the diagnosis changed and, if so, why, and whether the patient progressed the way the handing-off doctor expected.

"People love this. It's easy. It takes 5 minutes," he said. And the information can then be discussed in peer coaching sessions.

A Serious Problem

Recent reports show the gravity of the problem.

Medical record reviews suggest that diagnostic errors account for 6% to 17% of hospital adverse events, according to a landmark report issued last fall by the Institute of Medicine (now a division of the National Academies of Sciences, Engineering, and Medicine). And the overall diagnostic error rate is 5%, or one in 20 adults annually.

And the biggest factors in lawsuits against hospitalists are diagnostic errors, according to a study by The Doctors Company, a physician-owned medical malpractice insurer, which was presented earlier at the meeting, as reported by Medscape Medical News.

A Team Effort

One way to reduce errors is to involve more team members in the diagnosis, Drs Olson and Mathews point out.

Including a variety of team members, with varied expertise, in the process is a good idea. "Elevate the people on your team — pharmacists, social workers, physical therapists. Ask the certified nursing assistant at the bedside, 'How's the patient doing?' That will help the diagnostic process," Dr Mathews explained.

It is easy to get possessive with a diagnosis, for doctors to think they somehow own it, he pointed out.

We need to think louder, or our patients don't know we're doing it.

Keeping patients and families abreast of what is happening is also a good idea.

Often, families are left in waiting rooms imagining the worst and wondering what happened to the doctor who saw their loved one only briefly. Communicating well can calm fears and engage them in care, Dr Olson said.

"We need to think louder," he said, "or our patients don't know we're doing it."

He said he would also like doctors to rate how sure they are about a diagnosis. "If I could do one thing in the electronic medical record, I'd put a slider bar in to show how sure you are." That feature could let the next doctor know that another look would be welcome.

The "thinking louder" approach works, said Lubna Khawaja, MD, from the Baylor College of Medicine in Houston. She reported that it is something she does personally, but said now she will more actively ask those she teaches to do the same.

But peer coaching might be a harder sell.

"With medicolegal issues weighing on everyone's mind and concerns about being 'second guessed,' I am not sure if this would be welcomed by colleagues," she told Medscape Medical News. "It may have to be done with clear disclaimers up front and under the umbrella of a 'formal peer review'," she said.

Dr Olson has received funding from The Doctors Company Foundation, the Alliance for Academic Internal Medicine, and the Agency for Healthcare research and Quality. Dr Mathews and Dr Khawaja have disclosed no relevant financial relationships.

Society of Hospital Medicine 2016 Annual Meeting. Presented March 8, 2016.


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