30 November 2015
An Oxford University study published in the British Journal of General Practice has explored GPs' mistakes in diagnoses, and how these can be avoided.
The study, from Oxford University’s Nuffield Department of Primary Care Health Sciences, used interviews with GPs to find common themes in cases where a misdiagnosis had occurred or was narrowly avoided. The team were interested in the approaches to clinical decision making that were implicated in diagnostic errors and also considered the implications of these findings for GP training.
British Journal of General Practice editor Roger Jones said: ‘Despite general practitioners' best efforts, diagnostic errors are made from time to time, but we still don't know enough about why GPs make mistakes and how to prevent them happening.’
The Oxford team identified several important themes: the limitations of pattern recognition, the importance of considering all potentially serious conditions using a ‘restricted rule out approach’ and difficulties in using 'red flag' symptoms to rule out serious conditions. Issues around dealing with diagnostic uncertainty and knowing how to respond to a 'sense of unease' about a particular patient were also discussed.
Lead researcher Dr Clare Goyder explained:
‘GPs often think in terms of patterns. That can be useful in quickly identifying some diagnoses, but when symptoms are unusual or presentations atypical, the lack of a pattern can be a hindrance – especially if the symptoms are not those that the GP would usually expect for that condition. Pattern recognition also relies on experience, so less experienced GPs cannot or should not rely on it too much.
‘We also rely on red flags – key symptoms or signs that can help alert us to a serious diagnosis. Although they are useful for some conditions, the lack of these red flags is not always reassuring and sometimes the red flags being used aren’t as accurate as the individual doctor may think. The key is to ensure trainees know how reliable particular red flags are and whether they do actually allow a serious condition to be ruled out.’
A recurrent theme was uncertainty. While GPs know that they have to accept a reasonable amount of uncertainty as inevitable, there are ways to reduce it. These include seeking the opinion of colleagues and ‘safety netting’ – making sure that patients are properly followed up or know what to do if symptoms evolve. The conclusion is that trainees should also ensure their tolerance of uncertainty is appropriate to the seriousness of a possible condition.
One theme, however, was not about knowledge, experience or procedure: gut instinct. A number of those interviewed talked about a sense of unease either during or sometimes after a consultation and the advice to trainees is to respond to this and reconsider a diagnosis if it feels wrong to them or to a patient or carer.
Dr Goyder said: ‘In some cases the instincts of patients or parents prompted doctors to reassess their diagnosis. In other cases, the doctor listened to their own instincts. But the message is to act on, rather than ignore, a feeling of concern.’
The authors conclude that medical education needs more emphasis on the decision making process and how to identify and avoid diagnostic errors, while GP trainees should be given the opportunity to learn from the errors of others. Meanwhile, they say, more research on how and why errors are made can help to improve medical practice.
Dr Goyder said: ‘GPs are unusual in the degree of uncertainty they must accept as part of their day-to-day work. Any training that helps GPs reduce that uncertainty and prevent errors will ultimately benefit patients.’
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The paper, Missed opportunities for diagnosis: lessons learned from diagnostic errors in parimary care is published in the British Journal of General Practice (doi: 10.3399/bjgp15X687889).
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