Penn State Hershey has solid foundation for improving diagnosis
While national attention is being drawn to the issue of inaccurate or delayed medical diagnoses, Penn State Hershey has been actively addressing issues that can lead to diagnostic errors with programs from medical education through to the clinic.
The Institute of Medicine of the National Academies of Sciences, Engineering and Medicine brought attention to the issue last week when it presented eight recommendations in its report, “Improving Diagnosis in Health Care.
The recommendations are a follow-up to the Institute of Medicine’s 2000 landmark report “To Err is Human: Building a Safer Health System,” and 2001’s “The Quality Chasm: A New Health System for the 21st Century,” both of which influenced patient safety measures at healthcare systems nationwide.
Dr. Timothy Mosher, chair, Penn State Hershey Department of Radiology, said that collecting accurate data to measure the scope of diagnostic errors is difficult. The issue is often underestimated. According to the institute’s report, most people will be victims of diagnostic error to one degree or another at some point in their lives.
“That fact itself should be enough of an attention-getter,” Mosher said. “We have to develop better systems.”
To help reduce errors, Penn State Hershey introduced the FailSafe program to its emergency department in 2012. FailSafe communicates all findings during a visit to not only the patient’s family doctor, but to the patient as well.
“There are things that show up on scans when someone is in the ER for other reasons,” said Dr. Michael Bruno, professor of radiology and medicine and vice chair for quality and patient safety. “We would ask the patient to follow up with their family doctor, but invariably, many wouldn’t do that. We wanted to do something to help those patients and communicate with them better.”
Findings are sent to the patient’s family doctor. If the patient does not have a family doctor a referral is made to a doctor in the Department of Family and Community Medicine. Patients are also sent a letter that details what should be followed up on, as well as an explanation of how a family doctor can get the report and images from the emergency department visit.
Bruno said the program has worked so well that the organization is considering expanding it to include all outpatient departments in the near future.
Follow-up calls referring to the letter are one thing he would like to add to the program to increase patient engagement.
The Institute of Medicine’s report recommends putting patients at the center of the healthcare team, involving them more in the diagnostic process, and developing a system and culture that improves the diagnostic process by identifying, learning from and reducing diagnostic errors and near misses.
At Penn State Hershey, an interdisciplinary muskoskeletal/osteosarcoma diagnosis team sits down to review and confirm or rethink new patient diagnoses. It has done so three times each month since 2007.
Dr. Ed Fox, orthopaedic oncologist, Dr. Donald Flemming, professor of radiology and orthopaedics, and Dr. Elizabeth Frauenhoffer, professor of pathology and orthopaedics, pool their respective areas of expertise with a common knowledge of orthopaedic oncology to make sure diagnoses do not occur in a vacuum.
Frauenhoffer said the practice is pretty standard in most academic pathology departments, although some review the cases afterwards for educational purposes rather than for diagnostic certainty and treatment planning.
“Medicine is not a black-and-white science,” Fox said. “It is an interpretation of things, and you don’t always get the whole picture from one report.”
Frauenhoffer said having a comfort level with each other makes it easier for the three of them to express doubt about a diagnosis or question another’s interpretation.
“We don’t have to keep up a façade that we know everything,” she said.
Flemming agreed that the dynamic of the group is important.
“The strength is that we are able to communicate openly,” he said. “We can embrace each other’s errors and be humble and not ridiculously critical, because we have all made mistakes.”
Sitting down in person and questioning possible errors in the process once helped the team keep a patient from receiving unnecessary chemotherapy.
“If we had been working in a silo, that wouldn’t have happened,” Fox said.
The Institute of Medicine report also highlighted medical education and training in the diagnostic process as a way to improve diagnostic accuracy.
About a year ago, Penn State College of Medicine hired a director of critical thinking and problem solving who works with college leadership to modify learning materials and course objectives so future physicians learn how to identify and address cognitive flaws and their role in diagnostic error.
This spring, a new critical thinking course will train students to “apply higher cognitive skills to deliberate thinking that leads to appropriate action.” Medical students will be evaluated on their ability to demonstrate skepticism, curiosity and uncertainty when confronted with new information. They will need to show they can hold competing information and ideas together, and that they can make a mindful evaluation of their own thinking processes and biases.
“I suspect we’re not unique, but it is unusual for a medical school to have a deliberate focus on this,” said Dr. Terry Wolpaw, vice dean for educational affairs at the College of Medicine.
The report’s focus on the need for teamwork in the diagnostic process won’t be anything new for College of Medicine graduates.
“Our students are learning in inter-professional teams from the day they walk in the door,” Wolpaw said. “The medical students work with nursing and physician assistant students so they learn to trust that other people in the team bring value and checks and balances to the thinking process.”
While plenty of work lies ahead as hospitals and health systems begin implementing recommendations, Mosher believes the Medical Center has a solid foundation to build on thanks to its efforts to date.
“The fact that we are thinking about and working on this issue shows that we are a bit ahead of the game,” he said.
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