Doctors, like the rest of us, make mistakes. Every year, upward of 12 million Americans see a physician and come away with a wrong diagnosis. The top cause? Bad judgment, said David Newman-Toker, director of the Johns Hopkins Armstrong Institute for Patient Safety and Quality’s Center for Diagnostic Excellence.
Newman-Toker found that judgment errors accounted for 86% of 55,377 medical malpractice claims he evaluated where misdiagnosis led to death or disability. It includes an assortment of knowledge gaps, inattentions, misinterpretations and what Angie Rosen believes led to the misdiagnosis of her stroke: implicit bias.
Implicit bias occurs when a physician’s unconscious assumptions get in the way of objectively assessing a patient. Rosen, 37, said she thinks her age, gender and possibly her same-sex spouse were behind an emergency room doctor’s dismissal of her symptoms.
Rosen experienced a stabbing pain in her head that became a migraine. Her left eye started drooping, her right side was numb, she couldn’t swallow. An ER doctor examined her, ordered tests and told her to go home. It was unlikely she had a stroke, he said. A neurologist concurred.
Rosen insisted she felt too ill to leave, and she was admitted. Two days later, the doctor said her studies did not indicate a stroke and discharged her.
Rosen’s migraine continued to rage, however. Her family took her to the Hospital of the University of Pennsylvania for another opinion. Within two hours, doctors determined she had suffered a stroke, admitted her and started treatment.
If you are having a stroke, there is about a 9% chance you will be misdiagnosed in the ER. But if you are young, female, a person of color or have less than a high school degree, your risk of misdiagnosis soars, Newman-Toker said. Rosen, in the 18-45 age group, was 700 times more likely than a 75-year-old to be misdiagnosed, his research said. Being a woman raised the risk a stroke would be missed by 30%.
Alyson McGregor, co-founder and director of the Sex and Gender in Emergency Medicine Division at the Warren Alpert Medical School of Brown University, said women get short shrift in health care. “It’s the bias of a whole medical system,” she said.
Then, there’s race. Black Americans with severe depression are four to nine times more likely to be misdiagnosed with schizophrenia compared to white Americans, said Stephen Strakowski, acting senior associate dean of research and a psychiatry professor at Dell Medical School at the University of Texas at Austin. As a result, they do not get the antidepressant or mood stabilizer they need and may suffer unnecessary side effects from schizophrenia medications.
People with mental illness may be affected the most by implicit assumptions overall, said Mark Graber, president of the Society to Improve Diagnosis in Medicine. For example, when a patient complains about abdominal pain, the doctors may tie it to depression or anxiety without testing.
Doctors get the diagnosis right 9 out of 10 times, Graber said. But patients need to speak up if they think a doctor is missing something.
By gathering medical records yourself to bring to an appointment, you give the doctor more time to think, Newman-Toker said.
Keep in mind that attributing a symptom to stress or anxiety can be a default position when a doctor is stumped.
“Ask ‘What is the most worrisome thing this could be and why isn’t it that?’ ” he said. If your doctor can’t support an opinion or is dismissive, it’s a red flag that the diagnosis may be a gut reaction, he said.
“If you are not reassured, get a second opinion,” Graber said.
“[Bias] may be a bigger problem than we think,” said Thomas Yuen of the Family Medicine Residency Program at Crozer-Chester Medical Center. “The final frontier [for physicians] could be our own judgment and emotions.”