Author: Richard K. Riegelman
This book looks at why doctors make mistakes, and what they can do to guard themselves against this. It reviews the doctor-patient relationship and how errors impair the diagnostic formulation and skew the investigation process. The author explores how the personality and attitude of doctors and patients affect the medical consultation, and he reviews how the doctor’s thinking influences decision-making.
The book discusses the risks that threaten almost every stage of the medical consultation. One such risk arises when the doctor relies excessively on the presenting complaint to formulate a diagnostic hypothesis. This practice lets the doctor ‘rapidly take control of the medical interview’, but increases the chances of diagnostic mistakes because ‘the presenting complaint may bear little resemblance to the principal problem…’ (pages 13-15 and 26). Patients find such consultations unsatisfactory as they only get the opportunity to raise their main concerns at the end of the session, something the author labels ‘the doorknob syndrome‘ (page 15). To get to the real complaint, the author urges the doctor to give up some control, and to ‘step back and refocus’ (pages 17 and 25).
The book delves into how the doctor’s thinking process may impair his or her judgment. The author discusses heuristics, cognitive shortcuts which often aid the diagnostic process, but lead to wrong conclusions if unchecked. The author illustrates this with the representativeness heuristic which makes doctors liable to jump to wrong conclusions. Another example is the availability heuristic which restricts the making of a broad differential diagnosis. Base rate neglect, on the other hand, facilitates diagnostic errors because the doctor does not consider the disease’s demographics. The author makes several recommendations to overcome heuristic diagnostic errors. An example is his suggestion to make a problem list before arriving at a final diagnosis. Other examples include his advice to think through differential diagnoses, and to consider the use of computerised diagnostic aids (pages 30-41).
A major topic the book explores is the role of uncertainty in medical decision-making. Acknowledging that ‘uncertainty is one of the unpleasant facts of life’, the author urges physicians to tolerate and learn to share their uncertainty with their patients (page 185). Pointing out that a diagnosis does not need to be made at all costs, he criticised doctors who carry out many unnecessary tests in an attempt to reduce uncertainty and allay the fear of litigation. He says ‘the tendency to leave no stone unturned, to tie up all the loose ends, to believe that time is of the essence, belongs more appropriately in the solving of a murder mystery than in medical diagnosis and treatment’ (page 186). Rather, he advocates keeping diagnoses open, maintaining good communication , and instituting close follow-up as effective measures to manage uncertainty, prevent mistakes, and fend off litigation (pages 63 and 187).
The book discussed how some patient characteristics may bias doctors and lead to mistakes. Physicians, for example, may not apply themselves sufficiently when assessing patients who they label entitled demanders, dependent clingers, or manipulative help rejectors. Other patients who may be similarly disadvantaged fall into JE Grove’s category of the hateful patient (page 182). The author advises physicians to recognise when they have negative feelings to their patients and understand how this may impair their decision-making. He proposed preventative measures such as including the patient’s personality in the differential diagnostic list (page 182-183).
The book highlights many other diagnostic pitfalls such as patients who do not have the classical features of their disease. This may occur when patients are in the early stages of their disease, or when they have co-morbid diseases. In these situations there is a risk that the doctor may unnecessarily search for zebras; these are rare diseases which should only be considered when the pattern of presentation is exceptionally unusual, and the diagnosis truly elusive (page 41-43). The book addressed many other diagnostic pitfalls such as mental models, physician denial, and physician arrogance.
The author sprinkles his book with many quotations relevant to diagnostic error. For example, he quoted Arthur Bloomfield who said ‘there are some patients whom we cannot help: there are none whom we cannot harm’ (page 113). He related William Osler saying that ‘medicine is a science of uncertainty and an art of probability‘ (page 184). An interesting quotation is the Chinese proverb which says ‘to be uncertain is uncomfortable; to be certain is ridiculous’ (page 184).
The large scale of medical error in healthcare is now well-recognised. The book focuses on the causes of diagnostic error and gives practical recommendations to address them. The author exhaustively covered the subject with very clear writing. There are very few books which address the important problem of diagnostic error, and the author has done an excellent job of it.
It is important for doctors to understand the pitfalls that threaten the diagnostic process, and how they may avoid these. This book has addressed this comprehensively and I recommend it to all doctors.
- Publisher, place, date: Little, Brown and Company, Boston, 1991
- Number of chapters: 14
- Number of pages: 228
- ISBN: 0-316-74523-5
- Price: £0.27
- Star rating: 5 stars