Avoiding diagnostic errors in psychosomatic medicine: a case series study
Tóm tắt
Non-organic lesions or diseases of unknown origin are sometimes misdiagnosed as “psychogenic” disorders or “psychosomatic” diseases. For the quality of life and safety of patients, recent attention has focused on diagnostic error. The aim of this study was to clarify the factors that affected misdiagnoses in psychosomatic medicine by examining typical cases and to explore strategies that reduce diagnostic errors. The study period was from January 2001 to August 2017. The data of patients who had visited the Department of Psychosomatic Medicine, Kindai University Hospital and its branches, Sakai Hospital and Nihonbashi Clinic, were collected. All patients were aged 16 years or over. Multiple factors, such as age, sex, presenting symptoms, initial diagnosis, final diagnosis, sources of re-diagnosis and types of diagnostic errors were retrospectively analyzed from the medical charts of 20 patients. Among them, four typical cases can be described as follows. Case 1; a 79-year-old woman, initially diagnosed with psychogenic vomiting due to depression that was changed to gastric torsion as the final diagnosis. Case 2; a 24-year-old man, diagnosed with an eating disorder that was later changed to esophageal achalasia. Case 10; a 60-year-old woman’s diagnosis changed from conversion disorder to localized muscle atrophy. Case 19; a 68-year-old man, appetite loss from depression due to cancer changed to secondary adrenal insufficiency, isolated ACTH deficiency (IAD). This study showed that multiple factors related to misdiagnoses were combined and had a mutual influence. However, they can be summarized into two important clinical observations, diagnostic system-related problems and provider issues. Provider issues contain mainly cognitive biases such as Anchoring, Availability, Confirmation bias, Delayed diagnosis, and Representativeness. In order to avoid diagnostic errors, both a diagnostic system approach and the reduction of cognitive biases are needed. Psychosomatic medicine doctors should pay more attention to physical symptoms and systemic examination and can play an important role in accepting a perception of patients based on a good, non prejudicial patient/physician relationship.
Tài liệu tham khảo
The Japanese society of psychosomatic medicine, editor. The handbook for the certification of the Japanese society of psychosomatic medicine. Tokyo: the Japanese society of psychosomatic medicine; 1996.
Graber ML, Carlson B. Diagnostic error: the hidden epidemic. Physician Exec. 2011;37(6):12–4. 16, 18-9
Graber M. Diagnostic errors in medicine: a case of neglect. Jt Comm J Qual Patient Saf. 2005;31(2):106–13.
Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493–9.
Norman GR, Eva KW. Diagnostic error and clinical reasoning. Med Educ. 2010;44(1):94–100. https://doi.org/10.1111/j.1365-2923.2009.03507.x.
McLaughlin K, Eva KW, Norman GR. Reexamining our bias against heuristics. Adv Health Sci Educ Theory Pract. 2014;19(3):457–64. https://doi.org/10.1007/s10459-014-9518-4. Epub 2014 Jun 3
Norman G, Young M, Brooks L. Non-analytical models of clinical reasoning: the role of experience. Med Educ. 2007;41(12):1140–5. Epub 2007 Nov 13
Phua DH, Tan NC. Cognitive aspect of diagnostic errors. Ann Acad Med Singap. 2013;42(1):33–41.
Norman G. Dual processing and diagnostic errors. Adv Health Sci Educ Theory Pract. 2009;14(Suppl 1):37–49. https://doi.org/10.1007/s10459-009-9179-x. Epub 2009 Aug 11
Graber ML, Kissam S, Payne VL, Meyer AN, Sorensen A, Lenfestey N, et al. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual Saf. 2012;21(7):535–57. https://doi.org/10.1136/bmjqs-2011-000149. Epub 2012 Apr 27
Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775–80.
van den Berge K, Mamede S. Cognitive diagnostic error in internal medicine. Eur J Intern Med. 2013;24(6):525–9. https://doi.org/10.1016/j.ejim.2013.03.006. Epub 2013 Apr 6
Ely JW, Graber ML, Croskerry P. Checklists to reduce diagnostic errors. Acad Med. 2011;86(3):307–13. https://doi.org/10.1097/ACM.0b013e31820824cd.
Schiff GD, Kim S, Abrams R, Cosby K, Lambert B, Elstein AS, et al. In: Henriksen K, Battles JB, Marks ES, Lewin DI, editors. Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project. Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology). Rockville: Agency for Healthcare Research and Quality; US; 2005. p. 255–78.
Trowbridge RL. Twelve tips for teaching avoidance of diagnostic errors. Med Teach. 2008;30(5):496–500. https://doi.org/10.1080/01421590801965137.
Katakami H, Ishikawa E, Hidaka H, Ushiroda Y, Yamaguchi H, Yonekawa T, et al. Clinical feature, incidence, and prevalence of isolated ACTH deficiency (IAD). ACTH related Peptides. 2007;18:29–32. [Japanese]
Morigaki Y, Iga J, Kameoka N, Sumitani S, Ohmori T. Psychiatric symptoms in a patient with isolated adrenocorticotropin deficiency: case report and literature review. Gen Hosp Psychiatry. 2014;36(4):449.e3–5. https://doi.org/10.1016/j.genhosppsych.2014.02.012. Epub 2014 Mar 5
Margolis RL. Nonpsychiatrist house staff frequently misdiagnose psychiatric disorders in general hospital inpatients. Psychosomatics. 1994;35(5):485–91.
Juergens SM, Rome JD, Ilstrup DM. Effect of inpatient psychiatry training on internal medicine residents. Results of a survey Gen Hosp Psychiatry. 1990;12(2):124–8.
Andersen SM, Harthorn BH. Changing the psychiatric knowledge of primary care physicians. The effects of a brief intervention on clinical diagnosis and treatment. Gen Hosp Psychiatry. 1990;12(3):177–90.
Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121(5 Suppl):S2–23. https://doi.org/10.1016/j.amjmed.2008.01.001.
Saravay SM, Koran LM. Organic disease mistakenly diagnosed as psychiatric. Psychosomatics. 1977;18(2):6–11.
Lucchiari C, Pravettoni G. The role of patient involvement in the diagnostic process in internal medicine: a cognitive approach. Eur J Intern Med. 2013;24(5):411–5. https://doi.org/10.1016/j.ejim.2013.01.022. Epub 2013 Feb 17
Schuepbach WM, Adler RH, Sabbioni ME. Accuracy of the clinical diagnosis of ‘psychogenic disorders’ in the presence of physical symptoms suggesting a general medical condition: a 5-year follow-up in 162 patients. Psychother Psychosom. 2002;71(1):11–7.