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Diagnostic Reflection and Diagnostic Error Case Analysis

Robert Trowbridge M.D.

When first presented with general diagnostic checklists such as the modified Graber checklist, many physicians are offended.   Physicians rightfully take pride in their knowledge of the diagnostic process and are insulted that others believe they need to be reminded to complete basic tasks such as taking a complete history and performing a physical examination.  Yet we need to put aside these reservations and consider the value of checklists demonstrated in other settings such as the aviation industry. Undoubtedly experienced airline pilots, for example, know how to complete each element of the pre-flight checklist and yet checklists have contributed to the remarkable safety record in that high-risk industry. 

In the presented case, it is probable that the use of a general diagnostic checklist would have had a significant impact on the care provided by both the primary care physician and the emergency physician.  In walking through the checklist at the initial visit, for example, it is likely that the primary care physician would have been able to check-off that an appropriate history and physical examination had been performed. It is unclear, however, whether a systematic approach to a patient with abdominal and back pain was employed.  Had the physician done this, it is very likely that the clinician would have arrived at a leaking or expanding aortic aneurysm as a potential, if not likely, diagnosis.  More importantly, taking time to reflect and use analytical reasoning as directed by the SAFER mnemonic would have helped substantially.  In considering the S for “serious diagnoses”, the clinician would have been forced to consider the absolute worst case scenario, which in a patient with back pain, abdominal pain and an abdominal aorta with increased diameter would have raised the specter of a leaking or expanding aneurysm.  Furthermore, forced consideration of A for “alternative diagnoses” would have accomplished much the same. The other applicable components of the reflection checklist (considering the physician’s feelings about the patient and considering extraneous data) would not have had a substantial impact on the course in this particular case. Lastly, however, it is clear that the final item in the checklist, which would have formally forced consideration of the need for close follow-up and contingency planning, could have impacted the patient’s course by spurring the development of a specific plan to be enacted if the patient’s pain worsened (i.e., immediate return for re-evaluation).

In a similar way, use of the checklist could have affected the care of the patient in the Emergency Department although other issues including communication difficulties and poor delineation of the role of the emergency physician were clearly contributory to the outcome in this case.  Had the general diagnostic checklist been used, it would have been immediately obvious to the physician that he/she had not completed the necessary history or exam on a patient with an abdominal aortic aneurysm present on CT scan.  Although this oversight may seem obvious in retrospect, and many may be incredulous the patient wasn’t examined in the emergency room upon acknowledgement of the CT results, all physicians have been in situations in which they haven’t completed required tasks because of the context of care in which they work (high clinical volume, difficult and complex patients, distractions, etc).  This demonstrates a key attribute of checklists…they remind us to do things we know we need to do, but don’t always do in actual practice.  The utility of applying the reflection component of the checklist for the emergency physician would be similar for the primary care physician.  Few clinicians, for example, would fail to recognize a leaking or expanding aortic aneurysm as a “worst case scenario” or Serious diagnosis in a patient with a known AAA and back pain.  Similarly, when explicitly prompted to use analytical reasoning in considering Alternative diagnoses to the proposed prostatitis, it is likely that a symptomatic aneurysm would have been more actively considered, thus prompting a more aggressive evaluation. Finally, the last item on the checklist could have been very useful.  In being prompted to “be a skeptic”, the emergency physician may have been obliged to re-evaluate the “established” diagnosis of prostatitis and complete a second independent evaluation with the knowledge that a significant aortic aneurysm was present.  This “fresh look” approach can be extraordinarily valuable, especially when new clinical information is available.  Few physicians, for example, would discount the diagnosis of a leaking or expanding aneurysm when given the following history: a middle-aged man with a known AAA of greater than 5cm presents with low back, abdominal and groin pain.

Recreating the context of a complex clinical case such as this one is difficult, but it appears that the use of a general diagnostic checklist may have impacted the care of this patient in a positive fashion. Although largely unproven, such checklists have significant potential as a powerful means of improving diagnostic reliability.

The Beacon
Second Quarter 2012