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How consultants can help juniors manage clinical uncertainty and avoid misdiagnosis

Delayed or misdiagnosis happens frequently. Some feel uneasy admitting this openly, but it must be discussed because of the harm it can cause, both to patients and doctors.

The worst possible consequence for patients is of course fatality. However, the effect on doctors can also be devastating; part of the reason so many of us ‘burn out’ is the expectation that we will always get things right, which is impossible.

Why does misdiagnosis happen? 

Misdiagnosis happens for various reasons including lack of knowledge, the fact that patients can present early in the disease history with non-specific symptoms, or present with an unusual combination of symptoms. Vital information can get lost in the system, and we often have to make quick decisions under pressure.

Cognitive biases also play a role, of which hundreds can potentially contribute. Our instinct to use heuristics to make quick diagnoses is efficient, but inaccurate, and we often mould new information we receive to fit the existing diagnosis rather than looking at it objectively. The idea of providing training to recognise and overcome cognitive biases has been around for over a decade, but is only just seeping into routine medical education.

Junior doctors need support

Misdiagnosis probably happens most frequently at registrar level, because you have the confidence but not yet the experience. You haven’t made enough errors to learn from, a lot of what you see is new and thought processes for differential diagnosis are not ingrained. Often you are working at night in a pressured environment without the time to really think about each patient.

You are also more potentially more isolated, because your support now is a consultant who may only be available by phone, who you may not know well, and you are expected to be more independent and make your own decisions.

What can we do?

We can help junior doctors embed the habit of thinking about differential diagnosis when we train them: instead of asking ‘what is the diagnosis?’ we should ask ‘what could the differential be, and what is most likely? How could you confirm which is correct?’ This is starting to happen more, albeit inconsistently.

Using a clinical reasoning tool to produce a list of relevant diseases can also help us to think more laterally. Because doctors still have limited time, these tools must be quick and easy to use and integrate into medical records.

In time it is hoped that they will produce a list of differential diagnoses with their probability and recommend further investigations to reduce the problems with making the right diagnosis.

Dr Mark Dayer is a consultant cardiologist with over 10 years’ experience, specialising in inherited cardiac conditions, devices and congenital heart disease

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