Stories of shocking medical errors that occur because doctors miss something during a physical exam — or forget to examine a patient at all — are common. Every physician knows them, says Stanford physician Abraham Verghese.
A missed breast mass in a patient that presents with chest pain. A missed gunshot wound in a patient wheeled into the emergency room. A missed pregnancy in a patient with a large belly.
But little has been done to quantify this type of medical error. In a first step toward creating data-based measurements of medical errors due to inadequacies in the physical exam, a study published recently in the American Journal of Medicine reports on a collection of 208 such occurrences, and their consequences.
I think of it as my worst nightmare, that a patient will slip through my grasp with a diagnosable or treatable condition.
Researchers collected the incidents from responses to surveys sent to 5,000 physicians asking for first-hand stories of such medical errors. The cause of the oversights in the 208 responses was most often a failure to perform the physical examination at all — in 63 percent of the cases, the study states. Other times, errors were caused by misinterpretating or overlooking physical signs.
"I think of it as my worst nightmare, that a patient will slip through my grasp with a diagnosable or treatable condition," says Verghese, who is known as a champion of bedside medicine. "I call it the ‘low hanging fruit,'" he says, referring to the simple yet essential process of conducting the physical exam — and its low cost.
The consequences of these mostly preventable mistakes varied from missed or delayed diagnoses in 65 percent of the patients, to incorrect diagnosis in 27 percent or unnecessary treatment in 18 percent, the study says.
"We are talking about missing things that are very common, a mass, or a sore or a heart murmur or something in the lungs, that leads you down the wrong path," says John Ioannidis, MD, senior author of the study. "This is something that happens everyday, and it’s something that could be corrected to a good extent."
A well-known report conducted by the Institute of Medicine titled, "To Err is Human," found that medical errors cause nearly 100,000 deaths per year, according to the study. The extent to which physical examination errors contribute to this figure remains uncertain and, as a result, little has been done to prevent them, it says.
"I doubt that anyone will come out and say we don’t need to have physical exams, but in real life, this is something that unfortunately gets lost," Ioannidis says. "Doctors think that it's OK, that the X-ray or the CAT scan will tell the story."
In reality, that’s just not the case, he says. The study's list of 208 medical errors reveals many such instances. For example, one physician missed a rash indicating shingles in a patient who presented with chest pain, which lead to an unnecessary coronary angiogram before the correct diagnosis was made. Another physician missed a scar for gastric bypass surgery which would have explained the patient's malnutrition, weight loss and a rare vitamin deficiency, delaying treatment.
"What we see is that these are mistakes and errors that any physician can make," Ioannidis says. "In many cases, it wasn’t any fancy thinking, someone just didn’t look."
Previously: At first ever Stanford Medicine 25 Symposium a focus on bedside-medicine and a call for community, A call for extended bedside manner training and Better communication between caregivers reduces medical errors, study finds
Photo by JoAnn Moravac, U.S. Army