Misdiagnosis

In the nested manner of blogging, 3quarksdaily reports on a New York Times article on a JAMA (Journal of the American Medical Association) article*. Chilling:

"With all the tools available to modern medicine — the blood tests and M.R.I.’s and endoscopes — you might think that misdiagnosis has become a rare thing. But you would be wrong. Studies of autopsies have shown that doctors seriously misdiagnose fatal illnesses about 20 percent of the time. So millions of patients are being treated for the wrong disease.

As shocking as that is, the more astonishing fact may be that the rate has not really changed since the 1930’s. "No improvement!" was how an article in the normally exclamation-free Journal of the American Medical Association summarized the situation.

This is the richest country in the world — one where one-seventh of the economy is devoted to health care — and yet misdiagnosis is killing thousands of Americans every year.
How can this be happening? And how is it not a source of national outrage?
A BIG part of the answer is that all of the other medical progress we have made has distracted us from the misdiagnosis crisis."

This extract pitches the story as a "national" outrage that thousands of "Americans"(by which I presume the writer means US residents, as opposed to Canadians, Brazilians, Argentinians, etc) are being killed by misdiagnosis every year. I am sure it is not just a US problem, though. Cold comfort indeed.

Accuracy of language aside, there is a spirited defence of the medical system in the comments (by an anonymous person):

"Comparing the diagnoses of myriads of diseases that afflict the human body with flying a commercial airliner is simply specious: no matter how complex the airliner, it was built by man, with every aspect of its construction, its parts and its operation documented and detailed.

By contrast, a physician sees a patient with limited information and a very limited amount of time (no thanks to the health insurance system), and is then expected to deliver near-perfect diagnoses about just what is wrong. Should I add that they are also expected to do this while keeping the admittedly soaring healthcare costs under control?

Physicians and surgeons make mistakes because they are overworked, under-resourced, and have limited amounts of time with each patient. But even more importantly, mistakes occur because the myriad human diseases each have myriad presentations, many that are basically (overlapping) non-specific symptoms. Should physicians send every patient who comes in with a splitting headache off for a CT to rule out a brain tumor? "

So the situation is that more people are being saved by modern medicine than were saved 100 years ago, but that because medicine is now technical and sophisticated, the definition of "mistake" has become more elastic. See my post below about ability to operate new technology as one gets older and has to forget old knowledge and relearn new, over and over again. Must be hard for doctors to keep up. What "anonymous" is pointing out is that the baseline is much better, even with errors (if they can be called errors when they might be things like not ordering every possible test for every possible condition for every presenting patient) taken into account.

* There is no JAMA article. I read the NYT article, after having to register for their site (they require personal info), and found it a string of anecdotes with an unreferenced one-word quote from JAMA somewhere in the middle. No context. No year, even. Low-standard journalism (not to mention zero marks for scholarship).

Dave Lull said…

The "No improvement" quotation is from this article:

Low-Tech Autopsies in the Era of High-Tech Medicine by George D. Lundberg, JAMA, Oct. 14, 1998.

It’s linked to from this article: How Often Are Patients Misdiagnosed? which is linked to from the article you quote from; the link is near the bottom of the page below some ads and under the heading "Related Articles."

6:35 AM

Dave Lull said…

"No context. No year, even. Low-standard journalism (not to mention zero marks for scholarship)."

And no link to the JAMA article right at the place of quotation. Zero marks for saving the time of the reader. To find it I used Google to travel a circuitous path that took me back to the NYTimes website. Then I had to backtrack to find it’s connection to the article you quote from. BTW I think the first NYTimes reference to it at least on the web was in this article:

Buried Answers, by David Dobbs, published: April 24, 2005.

Mr Dobbs refers to it more fully than Mr Leonhardt but doesn’t link to a copy of it:

"Dr. George Lundberg, a pathologist who edited The Journal of the American Medical Association from 1982 until 1999 and now edits the online medical journal Medscape General Medicine, has, like Schiller, spent much of his career trying to revive the autopsy. The heart of his plaint is that nothing reveals error like the autopsy. As Lundberg noted in a 1998 article, numerous studies over the last century have found that in 25 to 40 percent of cases in which an autopsy is done, it reveals an undiagnosed cause of death. Because of those errors, in 7 to 12 percent of the cases, treatment that might have been lifesaving wasn’t prescribed. (In the other cases, the disease might have advanced beyond treatment or there might have been multiple causes of death.) These figures roughly match those found in the first discrepancy studies, done in the early 1910’s. ‘No improvement!’ Lundberg notes. ‘Low-tech autopsy trumps high-tech medicine . . . [Mr Dobbs’ ellipses] again and again.’"

3:31 PM

Maxine said…

Thank you for these clarifications, Dave. You have been more assiduous than the journalist or editor appears to have been.

What strikes me most about your research is the fact that the quoted JAMA phrase was written in 1998, 7 years ago. The distinct impression given in the NYT piece is that this is "news". The NYT piece does not actually lie, but comes pretty close.

(The Dobbs piece you cite is more accurate, making the source, and its date, plain. However, the extract you have given here, Dave, can hardly be used to make the point being made in the NYT piece, can it?! Some extrapolation, to use that piece, and quote about that piece about autopsies showing undiagnosed illnesses, to support the points the NYT article made about doctors’ errors.)

I am already very cynical about accuracy of media, so I am not entirely surprised about the laziness of the whole thing. (The commenter on the blog post is more knowledgeable than the NYT journalist, which makes me wonder if the NYT guy bothered to interview any working doctors before he wrote his piece.)

When I "grew up" and learned a few things, I was struck by how TV and most newspapers invariably get wrong a report on anything one happens to know anything about. So I don’t trust them on what I don’t know about either!

3:46 PM

Dave Lull said…

Based on part (/22leonhardt-side.html) of the URL for the article How Often Are Patients Misdiagnosed? I’d say that Mr Leonhardt also wrote that. He attempts to bring Dr Lundberg’s article’s relevance up to date by concluding that short piece with "[Dr Lundberg] said recently that it still reflected his views."

4:16 PM