ASSUMPTION IS THE MOTHER OF MISDIAGNOSIS.

A thirty something young executive came to a surgeon with complains of a swelling in the back and was promptly diagnosed as a lipoma (a harmless tumour of fat) because the surgeon could not find a punctum over the swelling. In a busy outdoor clinic, with more than a hundred patients waiting, he saw the patient from a distance and did not touch her. His mind went into a familiar path – back swelling with punctum – sebaceous cyst, without punctum – lipoma, and hence the diagnosis! Not satisfied she came to us and we felt a hard swelling attached to the scapula (a bone in the shoulder girdle). So, instead of a benign tumour of fat now we were dealing with a malignant tumour of muscle! This is what happens if we do not do the clinical drill and start assuming things that we would usually encounter.

There are a wide range of cognitive errors that lead doctors to make serious mistakes. Among them is ascertainment bias: we "see what we expect to see." For example, a dishevelled, homeless man staggering into the emergency room, slurring his speech, is assumed to be "drunk" when he may actually be hypoglycaemic or even urinary tract infection, which frequently manifests as delirium. When a disoriented old man was admitted to our unit, we expected to see someone who was either depressed or showing signs of a covert malignant tumour. We were not expecting to see someone in the early stages of sepsis, which only became obvious once we had the blood counts. We clinicians have this tendency to convince ourselves that what we want to be true is true, and we often blank out the less appealing alternatives.

Posting a specialist in the role of a general physician or an emergency medical officer is very dangerous. The same disoriented old man would be diagnosed by a psychiatry resident in emergency as Clinical depression  probably. Why, because he is more familiar with it and knew how to treat it. Sepsis probably is out of his portfolio of diseases. Whether we see what we expect to see or convince ourselves that what we want to be true is true, we are making unwarranted assumptions. A good medical training involves questioning one’s assumptions and avoids premature diagnostic closure.

The value of a good history and physical examination

The history and physical examination together with the ability to make difficult decisions are the key factors that distinguish the best clinicians. Taking short-cuts (for example failing to undress a child with pyrexia) will inevitably end in poor outcomes (delayed diagnosis of meningococcal septicaemia and loss of limbs or death in this particular example).  These are occasions when the clinician assumed a familiar and more common diagnosis or chose to rely on investigations. As teachers it is our duty to ensure that future generations of clinicians have good ethics and good clinical skills. No short-cuts here please!

Diagnostic acumen is the foundation of good medical care and a detailed history taking and physical examination are essential to sharpen our diagnostic acumen. These twin gems have been the cornerstone of teaching medical students. With the improvement in diagnostic modalities, however, there are some individuals who feel that these may not be as 'helpful' or 'reliable' as previously thought. Good clinical skills however, still protect patients from unnecessary investigations with the risk of false positive results and clinical risks that these investigations entail.

Make no mistakes, investigations are vital but regardless of their use in diagnosing a condition, patients still feel that the element of physical touch between a doctor and them is very important and provides a sense of satisfaction to them. The feel that 'they have been seen'. Medicine has always been an "art" as much as it wants to be a "science".  The "laying of hands" is not only an essential part of the Doctor-Patient Relationship - it may also be part of the treatment and essential for the cure. And most of the time, when a clinician is ‘laying his hand’, his mind opens up a bit more and there are lesser chances of him/her making erroneous assumptions.

Doctors have their own problems

In the developing countries because of a hopeless doctor-population ratio the doctors, particularly in government hospitals, are overburdened. It is not uncommon to find doctors besieged by patients from all sides, much like bees in a beehive, in their out-patient clinics. In such situations listening to a detailed history or conducting detailed physical examination of every patient is a Utopian dream. The doctors in private set ups have their own share of woes. The corporate management and the insurance companies force them to document many metrics, inputting data into their HIS / EHR systems, in order to meet requirements. Patients take this lack of eye-to-eye contact as a sign that doctors are more interested in their digital record than them. They feel that doctors are no longer listening to them. Lack of time and preoccupation with gadgets both are responsible for assuming common ailments and then relying on investigations for course correction at a later date.

Missed opportunities

Diagnostic error result in missed opportunities where something different could have been done to make the correct diagnosis earlier. . . . Evidence of omission (failure to do the right thing) or commission (doing something wrong) exists at the particular point in time at which the ‘error’ occurred. These missed opportunities could be caused by individual clinicians, the care team, the system, or patients. Diagnostic error can be defined as any mistake or failure in the diagnostic process leading to a misdiagnosis, a missed diagnosis, or a delayed diagnosis.

The diagnostic process has seven stages: (1) access and presentation, (2) history taking, (3) the physical examination, (4) investigations, (5) assessment, (6) referral, and (7) follow-up. A diagnostic error can occur at any stage in the diagnostic process, and there is a spectrum of patient consequences related to these errors ranging from no harm to severe harm. While all diagnostic process errors will lead to a missed, delayed, or wrong diagnosis, thankfully not all errors result in patient harm.

Medical diseases are becoming more complex, and people are living longer. There has never been a time where patients need to trust their doctors more. All doctors need to remember their oath and put the patient back in centre focus. Patients too need to learn that the vast majority us care about our patients and have their best interests in mind. We all need to become a team again. Patients need to regain our trust, and our profession needs to re-establish its integrity. We have to stop assuming the familiar and go back to the basics of history and physical examination.