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Both of her legs ached for weeks, but there had been no recent trauma or injury. Her legs were a dark red color and not getting any better. Allison, a relatively healthy, 57-year-old woman, came to the emergency room complaining of red and painful skin on her lower legs. After a history, physical exam and assessment, the emergency department admitted Allison to the hospital for IV antibiotic therapy for cellulitis, a potentially life-threatening bacterial infection of the skin and deeper soft tissue.
I was immediately interested in Allison's case, to provide her with care and also because of a study I was leading related to misdiagnosis for the problem area of patients with a red leg rash and presumed cellulitis. The study was designed to measure the accuracy of diagnosis by examining consecutive patients admitted to the hospital for cellulitis. Allison represented yet another case of the correct therapy for the wrong diagnosis, as she did not need hospitalization or antibiotics. When I spoke with Allison during a procedure that proved an alternative diagnosis, she told me that she had two prior admissions at other hospitals for similar symptoms. Following each admission, she had been treated with IV antibiotics and hospitalized for a week.
Her story is not unusual. At least one in five cellulitis patients in the United States each year is misdiagnosed incorrectly and hospitalized, given medication they don't need, and put at risk for dangerous complications.1-4 Consider that they are over 500,000 inpatient admissions for cellulitis in the United States every year. Using an average cost of $12,000 per admission, and an error rate of 20%, that's over one billion dollars in wasted healthcare costs. Worse than the cost is harm done to patients, as they can have a serious medication reaction to antibiotics or develop a serious infection from the hospital.
As physicians, an incorrect diagnosis eats at our souls. Being an accurate diagnostician is central to our identity, and we are rattled to our core if we harm a patient. But there is surprisingly very little sustained effort in US medical education and healthcare to improve physician thinking and decision-making. There is also little learning from our mistakes, as we often do not receive feedback from our peers when we make an incorrect diagnosis.
The recently published diagnostic errors report, “Improving Diagnosis in Health Care,” by the Institute of Medicine (IOM) will receive much attention, as it should. Just as the 1999 IOM report “To Err is Human” instigated the modern patient safety movement, the new report will be transformative because it substantiates how large a problem misdiagnosis is, and will force the medical care system to work on solutions.
The 2015 IOM report recommends several actions aimed at reducing diagnostic error. The drive toward accuracy begins with increased communication both between the doctor and patient and across the entire care team – this is stressed multiple times in the report. The Committee also emphasizes a proper and thorough history and physical exam and reducing the dependence and overreliance on diagnostic testing. Continuous learning is also key to the IOM report, both as part of formal medical school training but also as a feedback loop designed to capture information about when errors occur, so providers can review their performance and adapt.
There are many steps to be taken. One immediate action is to recognize that physicians cannot memorize it all – they require the best information at the right time, which is at the point of care. To curb medical misdiagnosis, our model of what a doctor is and does must change. The IOM diagnostic errors report forces us to think about augmenting our brains, not with simple computer-based references or reliance on more tests, genetic studies and x-rays, but with new cognitive support systems designed to pull the history and physical exam together to answer questions as we work. New digital systems accessible on smart devices will engage patients and replace the outdated waiting room clipboard screening questionnaires. Now that the IOM is helping the public realize the extent of the diagnostic errors problem, we can start to invest in new point-of-care information tools as well as new methods to aid thinking, and hopefully diminish the number of patients who are misdiagnosed every year.
1.David CV, Chira S, Eells SJ, et al. Diagnostic accuracy in patients admitted to hospitals with cellulitis. Dermatol Online J. 2011;17(3):1. [PubMed]
2. Ellis Simonsen SM, van Orman ER, Hatch BE, Jones SS, Gren LH, Hegmann KT, Lyon JL. Cellulitis incidence in a defined population. Epidemiol Infect. 2006;134(2):293-299. [PubMed].
3. Levell NJ, Wingfield CG, Garioch JJ. Severe lower limb cellulitis is best diagnosed by dermatologists and managed with shared care between primary and secondary care. Br J Dermatol. 2011;164(6):1326-1328. [PubMed].
4.Arakaki RY, Strazzula L, Woo E, Kroshinsky D. The impact of dermatology consultation on diagnostic accuracy and antibiotic use among patients with suspected cellulitis seen at outpatient internal medicine offices: a randomized clinical trial. See comment in PubMed Commons belowJAMA Dermatol. 2014 Oct;150(10):1056-61[PubMed]
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