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Challenge to diagnosing


Patient factors, physician factors and system factors

Failure to diagnose


Puzzle with outlines of two missing pieces
  • Failure to diagnose is a common allegation in legal actions.
  • Non-specific and atypical presentations of diseases are common.
  • Cognitive biases can interfere significantly in the ability to reach a correct diagnosis.
Failure to diagnose is one of the most frequent allegations in legal actions against physicians in Canada. Even the most experienced and knowledgeable physicians have difficulty diagnosing every patient; that's why missing a diagnosis usually does not constitute negligent medical care.

The courts will not evaluate your decisions against a standard of perfection. Rather, your decisions will be evaluated in light of what a reasonable and prudent physician would have decided in similar circumstances.

Delays in diagnosis are most often related to the variable progression of the pathophysiology of a disease. Formulating a final diagnosis is a process that often occurs over time and several patient encounters.  

Although some diagnoses are immediately apparent, many conditions are initially masked and must progress to a clinical degree where the symptoms and signs suggest the diagnosis or at least indicate the need for further investigation. Many diseases are non-specific in the way they manifest themselves: atypical presentations compared to the classic descriptions in textbooks are common for many conditions.

Many things can influence the assessment of a patient. These can be grouped into three categories as shown in this table.

Patient factors

  • language barriers
  • health literacy
  • expectations
  • ability to cooperate

Physician factors

  • knowledge and experience
  • communication skills
  • cognitive biases
  • multi-tasking
  • fatigue
  • illness

System factors

  • processes of care
  • sensitivity and specificity of tests
  • information management
  • available resources


Think about it

Can you think of others?