Originally published December 2012
Delays in diagnosis may result from the variable progression of pathophysiology, unusual presentations of diseases, failures in the processes of care, or issues with the performance of physicians or other providers.
Failure to diagnose is one of the most frequent allegations in legal actions against physicians in Canada. An analysis of CMPA medico-legal pediatric cases that closed between 2007 and 2011 identified 179 with issues in clinical diagnosis. The analysis identified a number of common themes that are illustrated in the following case examples.
Case 1: Inappropriate delegation and supervision, and failure to appreciate the severity of illness
A 5-year-old child with severe cerebral palsy and developmental delay arrived in an emergency department with fever and vomiting.
He was assessed by a junior resident who noted this spastic child had tachycardia and tachypnea. The abdominal exam was extremely difficult. The resident diagnosed a viral gastroenteritis, reviewed his impression with the attending physician, and discharged the child. Two days later, the child returned in septic shock secondary to peritonitis due to a ruptured appendix. Experts were critical of the supervising physician for not examining the child personally at the initial visit, especially given the fact that this was a complex patient, assessed by an inexperienced learner.
Delegation and supervision of medical acts is a vital part of medical training. Both supervisors and trainees have obligations in these situations. Before assigning tasks to trainees, supervisors should know the trainees' abilities well enough to be confident in their judgment. As well, supervisors should sufficiently understand a patient's situation before providing clinical guidance to trainees, especially if the supervisor has not personally seen a patient. Trainees should communicate their strengths and weaknesses to their supervisors and keep them apprised of patient conditions over time. For more information on delegation and supervision, see the CMPA article, "Delegation and supervision of medical trainees".
Case 2: Inappropriate diagnosis without adequate clinical support
A 13-year-old patient complained of dysuria and lower abdominal pain.
She had no history of urinary tract infections (UTI) and had a family history of autoimmune nephritis. Over the course of 5 months, the patient submitted 17 urinalyses that were repeatedly abnormal with large numbers of red cells, white cells and casts, and moderate bacteria and protein ranging from 1+ to 3+. Each time, the family physician diagnosed a UTI and prescribed various antibiotics despite the lack of pure growth of any organism. A specialist consultation was eventually sought which highlighted the family history and the personal history of weight gain, edema, periorbital swelling, and thirst. The patient was admitted urgently with glomerulonephritis and renal failure secondary to Systemic Lupus Erythematosus. In the subsequent legal action, the medical experts who were asked to comment on the care were critical, stating the family physician should have reconsidered the diagnosis of UTI given the many assessments and repeated treatment failures. The CMPA paid a settlement to the patient and family on behalf of the member family physician.
Many medical regulatory authorities (Colleges) are encouraging the use of cumulative patient profiles (CPPs). Ideally, CPPs include personal and family data, past medical history, risk factors, allergies, ongoing health conditions, long-term treatment, and major investigations, as well as health maintenance data, consultant's names, and contact information. CPPs are meant to provide a snapshot picture of a patient's medical problem over time to identify broader health issues. CPPs may help identify potential trends or highlight inconsistent data in need of attention. Physicians should review the information in the CPP regularly and revise it to prevent it from becoming outdated.
Case 3: Dismissing parental concerns without a thorough assessment
A child with varicella was brought to an emergency department due to blackened lesions and pain when walking or if touched anywhere.
The physician felt the lesions were consistent with chicken pox. Although the child screamed in pain when picked up, the physician suggested the complaints likely represented attention-seeking behaviour, given the recent birth of a sibling. Two days later the child was diagnosed with a group A streptococcal necrotizing fasciitis. A complaint was made to the College. The College was critical of the physician's care since she only performed a visual inspection and did not perform a physical examination to objectively evaluate tenderness. The College expressed concern that the physician ignored symptoms reported by the parents which indicated something more serious was taking place. The College cautioned the physician regarding her approach and failure to properly examine the patient.
Patients may have symptoms that do not immediately trigger concern on the part of the physician. Although symptoms frequently evolve over time and repeated visits are often necessary to allow for diagnosis, physicians should listen carefully to parents, objectively evaluate the symptoms, and discuss their importance with parents. In addition, accurate documentation of such evaluations will provide evidence of the care that was provided and may help shed light on conflicting versions of an event, should the care later be questioned.
Case 4: Failure to develop differential diagnosis or to reconsider a diagnosis
A 6-month-old infant was seen in a pediatric emergency department with irritability, decreased feeding, and anuria.
There had been no vomiting or diarrhea, and examination revealed dry mucous membranes and tachycardia. An electrocardiogram (ECG) showed a heart rate of 240 bpm. The physician considered this to be sinus tachycardia, and attributed the high rate to crying and volume depletion. A diagnosis of gastroenteritis was made and the child was rehydrated and discharged. The patient later returned with persistent symptoms and was diagnosed by another physician on ECG as having supraventricular tachycardia. Cardiac arrest followed which required cardiopulmonary resuscitation and other intensive treatment. The child eventually recovered.
A legal action followed. The pediatric experts who were asked to comment on the care stated it was unreasonable in this case for the initial pediatrician to diagnose gastroenteritis with these symptoms. The experts further stated such a high rate of tachycardia should not have been attributed to crying, and the initial physician should have better assessed and monitored the heart rate and repeated the ECG prior to discharge. The CMPA paid a settlement to the patient and family on behalf of the initially treating member pediatrician.
Cognitive biases are unconscious distortions of thinking that influence reasoning, judgment, and decision making. As an example in this case, the physician likely fell victim to the cognitive bias called premature closure. In premature closure, an initial diagnostic impression is chosen before other differential diagnoses are properly excluded, for example, fixating on certain information (the tachycardia and dry mucous membranes) and ignoring other important information (the absence of vomiting and diarrhea), which might disconfirm an initial hunch. Cognitive biases might be avoided by forcing oneself to routinely challenge the soundness of one's thinking by asking questions such as, is there anything that does not fit?, what else could it be?, or, is there more than one thing going on?
Case 5: Failure to follow up on investigations
A 16-year-old male saw a cardiologist for evaluation of syncope.
The ECG was normal and the cardiologist ordered Holter monitoring and a stress test. At a follow-up appointment, the family was advised the stress test was negative and therefore the cardiologist discharged the patient. One year later, the patient died suddenly. A chart review revealed the patient's Holter monitor results, which had shown evidence of Long QT Syndrome (LQTS), had been sent to his family physician and not to the ordering cardiologist, who had not noticed that the results had never been received. Experts who were asked to comment on the care in this case were critical of the cardiologist, stating she should have followed up on the Holter monitor results. The CMPA paid a settlement to the patient's family on behalf of the member cardiologist.
Missed test results are a significant cause of patient morbidity and mortality. While they may result from any combination of factors — patient, physician, consultant, office, laboratory, or hospital factors — and the liability for lost results may be shared, courts and Colleges have stated it is the ordering physician's responsibility to follow up on investigations the physician has ordered. Physicians should have a system in place that identifies missing results and flags those that require follow up. More information on the follow-up of investigations can be found in the CMPA article, "How effective management of test results improves patient safety".
Minimizing diagnostic delays
Diagnostic delays occur for many reasons. Some may be minimized by considering the following questions:
Is a trainee receiving the appropriate level of supervision and support?
Is a system in place to allow tracking of test or diagnostic imaging results?
Have alternate diagnoses been considered for children with persisting symptoms?
Were the parents' concerns listened to and adequately addressed?
Contact the CMPA for medico-legal advice
More information on delegating and supervising, following up investigations, and communicating with patients is available on the CMPA website. The following articles may be of particular interest: "How effective management of test results improves patient safety," and "Physician-patient communication: Making it better." Members with specific questions are encouraged to contact the Association to speak with a medical officer, physicians with extensive medico-legal knowledge and experience.