After returning from a business trip to Malaysia six years ago, Joe Cherry began suffering from a flulike illness, then woke up one day with a crushing pain in his arm and chest. Once a heart attack had been ruled out, the emergency-room doctor diagnosed carpal tunnel syndrome, a painful wrist condition. "I used to work for a company [that] made devices for carpal tunnel surgery," recalls Cherry, 62, "and I knew this wasn't what I had." He saw three more physicians over four weeks before finally getting answers.
Doctors are stumped by symptoms all the time, and by prescribing the wrong medication, they often worsen the problem or even create a new one. Worse, misdiagnoses lead to an astounding 40,000 to 80,000 hospital deaths every year, according to a March paper published in the Journal of the American Medical Association—plus an uncounted number due to mistakes in the doctor's office. In fact, some 5 percent of autopsies find a condition missed by doctors that, if treated, might have saved the patient's life.
Certainly, some diagnoses—like strep throat—can be made in minutes. But the head-scratchers require a doctor with the patience to probe, plus a sharp set of mental skills that include a willingness to question his or her own logic—which can be tough to do in a 15-minute office visit. "Doctors are like detectives," says Jerome Groopman, professor of medicine at Harvard University and author of the bestselling How Doctors Think. "They sometimes encounter red herrings and make connections that are incorrect." While tumors and inherited diseases have become easier to pinpoint, thanks to genetic testing and ultrarevealing imaging, some experts worry that doctors too often rely on technology as a replacement for old-fashioned reasoning and history taking.
Part of the blame can be placed on sagging reimbursements and increased job pressures. For doctors at top academic hospitals, "the emphasis is on research, new discoveries, grant dollars," says John Flynn, clinical director of internal medicine at Johns Hopkins Hospital. "It's tough to do all the clinical care you need to develop your expertise and [also] survive in an academic institution." Doctors in private practice, paid by the test and procedure rather than by the minute, are finding that in-depth conversations are a luxury they can no longer afford.
New York City internist Tom Bolte decided 14 years ago to stop taking health insurance when his reimbursements for office visits fell from $45 per patient to $22.50—forcing him to nearly double his patient load. Now, specializing in tough-to-crack diagnostic cases, he typically sees only three or four patients a day and spends at least two hours on an initial visit for a fee of $250 to $450. Plenty of people with unexplained, unremitting pain are willing to travel across the country to see him and to fill out a 32-page questionnaire detailing symptoms, family history, sensitivity to cleaning products—even whether they have an attached garage, which may trap noxious fumes. One recent success: A woman discovered after multiple misdiagnoses that her headaches, hives, and fatigue were linked to a faulty gas pipe in her apartment.
While treatment mistakes like dispensing an overdose of medication are often caused by technical glitches, misdiagnoses are usually the result of flaws in a physician's thinking, says Groopman. Doctors, like the rest of us, sometimes make mistakes because they take "cognitive shortcuts," or jump to conclusions—an overweight man clutching his chest must be having a heart attack, for example—and then can't budge even when contradictory evidence emerges. Blame the 18-second rule. "That's the average time it takes for a doctor to interrupt you as you're describing your symptoms," says Groopman. "By that point, he has in mind what the answer is, and he's probably right about 80 percent of the time."
It's not that a doctor lacks sufficient clinical knowledge—one study suggests that only 4 percent of misdiagnoses are caused by that—but rather is tripped up by his or her biases. "When I supervise the training of medical students, I often tell them to ask themselves, if you're wrong in your diagnosis, what is the thing that you might have been wrong about?" says Robert Wachter, chief of hospital medicine at the University of California, San Francisco Medical Center. "I'm trying to get their minds to work differently, to question their own thinking." Bolte recently saw a man with severe abdominal pain who had been diagnosed with an intestinal infection and put on antibiotics. "His previous doctor never asked him about his diet," says Bolte, who quickly discovered the man, though deceptively thin, "survived on candy, ice cream, and McDonald's." The cure: whole grains and produce.