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Problems with doctor-patient encounter cause most primary care diagnosis errors

Breakdowns in the physician-patient encounter, most notably "cognitive errors" by doctors, are the most frequent causes of diagnostic errors in the primary care setting, according to new research.

Most of the cognitive errors identified in the study were related to problems with history taking (56%), physical examination (47%), and ordering diagnostic tests for further workup (57%), according to the research, which was published in JAMA Internal Medicine.

"Our findings highlight the need to focus on basic clinical skills and related cognitive processes (e.g., data gathering within the medical history and physical examination and synthesis of data) in the age of increasing reliance on technology and team-based care to improve the healthcare system," the researchers wrote.

The investigaters reviewed 190 diagnostic errors that occurred across two primary care practices—one a large urban Veterans Affairs facility and the other a large integrated private healthcare system.

Most missed diagnoses were common conditions in primary care, with pneumonia (6.7%), decompensated congestive heart failure (5.7%), acute renal failure (5.3%), cancer (primary) (5.3%), and urinary tract infection (4.8%) the most common.

To determine diagnostic errors, researchers reviewed electronic health records and classified a misdiagnosed patient as one who was hospitalized or returned to a doctor's office within 2 weeks of the initial physician-patient encounter.

Most of the diagnosis errors "have potential to lead to moderate or severe harm" to patients, the researchers noted.

In an accompanying editorial, two physicians noted that shortened office visits that offer little time for physician-patient dialogue are likely one factor that contributes to diagnostic errors by primary care physicians. Still, adding more time to doctor-patient encounters will hardly be a cure-all, the editorial noted.

"If we are to improve diagnostic accuracy without dramatically reducing efficiency, there may be no substitute for problem-specific solutions—in other words, for having knowledge and experience linked directly to presenting symptoms and diseases," the editorial stated.


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