Accuracy

Definition

Accuracy in medicine means getting the right diagnosis, choosing the right treatment, and ensuring the plan is followed through. It depends on three things: mastering the specific details of your case, applying the most current medical research, and oversight of the entire process. Accuracy in medicine is vital. Your health depends on it.

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Error in Medicine

The error rate in the practice of medicine is surprisingly high. The error rate for diagnosis, for example, is estimated at 10-15%. This means that 10-15% of the diagnoses from your doctor are wrong. The Institute of Medicine has approximated that the damage from all of these errors is responsible for 100,000 deaths every year in the US. These figures may be exaggerated; nonetheless, a fraction of these numbers is still too much.

Some of these errors are unavoidable. They are inherent in the practice of medicine and reflect current limitations in our knowledge. However, other errors are avoidable and easily corrected. For example, in the late 1990's it was observed that sleep deprivation of interns in hospitals was causing patient deaths. Subsequent enforcement of shift work, with manageable hours and manageable workloads, lead to a decline in errors.

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Sources of Medical Error

Medical regulators and licensing bodies have invested a lot of resources to studying the correctable sources of error. The following are the most common:

Physician Burnout

A mental condition experienced by overworked physicians affecting their performance. Over 50% of physicians report burnout. Studies (here and here) show that physicians with burnout make significantly more medical errors.

Decision Fatigue

Too many decisions leads to an inability to make more decisions. For example, at the end of a busy day primary care doctors: prescribe unnecessary antibiotics and opioids, forget to offer vaccines, mammograms, and colonoscopies, and neglect to wash their hands. 

The Erosion of the Clinical Encounter

Despite advancements in imaging and laboratory technology, a thorough history and physical examination remain the most powerful diagnostic tools, capable of identifying up to 90% of clinical conditions. In a high-volume system, the average physician interrupts a patient history within seconds - often as few as seven - preventing the discovery of subtle but critical details of the case.

Faulty Reasoning

Our brains evolved to process the world around us quickly and with little effort. Although this worked for basic survival in the savannah, for more complex tasks like diagnosis, it leaves our brains prone to errors called ​cognitive bias. For example, the availability heuristic: we tend to be drawn to diagnoses that we have made in the past or those that are dramatic. Or the base-rate fallacy: we tend to ignore the prevalence of the disease. Or premature closure: we tend to stick with the first diagnosis that comes to mind.

Obsolete Medical Knowledge

Medical knowledge now grows at an exponential rate becoming obsolete almost as fast as it is learned. Without dedicated time for update, a physician’s knowledge base can become obsolete shortly after their training ends.

System Errors

Faults in the process between diagnosis and treatment. This includes: communication errors, lost lab results, or a lack of follow-through.

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Engineering For Accuracy

Accuracy is not an accident; it is the result of a practice model engineered to eliminate the sources that lead to error. By prioritizing clinical rigor over patient volume, the concierge model provides this framework by:

Eliminating Burnout and Fatigue

By capping my practice at 300 patients and seeing less than three patients per day, the primary drivers of burnout and decision fatigue are removed. Every patient is approached with the same mental clarity and "fresh eyes" usually reserved for the first appointment of the morning.

Prioritizing the Clinical Encounter

My practice is built on the reality that the most sophisticated diagnostic tool is an uninterrupted conversation. By eliminating the 15-minute time constraint, I can perform a comprehensive history and physical for every case.

Correcting Faulty Reasoning through Time

Overcoming cognitive bias requires a transition from rapid, intuitive thinking to deliberate, analytical thinking. By allotting an hour or more for every visit, we create the intellectual space required to identify these biases, reconsider initial assumptions, and maintain the intellectual humility necessary for a truly accurate diagnosis. (If you are interested in learning about abduction please check out my Grand Rounds lecture on the topic.)

Maintaining Current Medical Knowledge

I treat medical school as only the beginning of a lifelong learning process. Because I am not required to process a high volume of cases, I spend approximately one-third of my day engaged in research and continuing education. To consolidate this learning, I share this knowledge with my patients in my Blog. This ensures that the care you receive is based on the most current evidence, not on habits formed decades ago.

Engineering Continuity and Failsafes

System errors are prevented through good continuity of care practices. I have structured my practice and trained my team to oversee every step of your care - from the moment a test is ordered to the final confirmation of the result. This process is seamlessly accomplished with several engineered features and failsafes, including: direct access, user-friendly electronic medical records, closed-loop communications, flowsheets, automated reminders, and automated drug interaction checkers.