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Press Release - Doctors ‘silent’ misdiagnoses cost patients dearly … and US health care billions

There are dramatic differences between what treatments patients want and what doctors think they want, according to a new study published today (Thursday 8 November 1830 EST) on bmj.com by the prestigious UK medical journal. For example, doctors believe that 71 percent of patients with breast cancer rate keeping their breasts as a top priority, but the actual figure reported by patients is just seven percent.

Disparities such as these result in what researchers call 'silent' misdiagnoses – when doctors choose the wrong treatments because they fail to assess their patients' preferences correctly. These misdiagnoses are 'silent' because they go largely unreported and even unrecognized.

The study shows that the problem of 'silent' misdiagnosis is widespread in both the US and UK, as well as in other health services around the world. Doctors in general are unskilled at diagnosing what patients want because they assume that the right treatment choice is a matter of scientific evidence alone. Even when a range of valid treatment options exist, they often neglect to ask patients about their preferences or simply assume that they will be the same as their own.

Studies have shown that many patients are poorly informed by their doctors about the potential risks and benefits of different treatments. They also suggest that patients who do have the opportunity to understand and evaluate their options frequently make different choices:

  • In one review of benign prostate disease, 40 percent fewer patients chose to have surgery when they learned that the relief it could bring to their urinary symptoms would likely be offset by sexual dysfunction;
  • In another study of back pain, patients with herniated discs who gained a better understanding of the evidence were more than 30 percent less likely to opt for surgical intervention.

Only last week, an independent review of breast screening in the UK estimated that one in five women aged 50 -70 diagnosed with breast cancer every year have treatment for a condition that would never have been a threat to their health in their lifetime. At the moment, technology does not allow doctors to say which tumors will grow and become harmful, and which will not. As such, the review concluded, the emphasis needs to be on providing women with much clearer information on both the potential harms and benefits of screening, so that they can make an informed choice for themselves.

A heavy cost for both patients and health care systems

'Silent' misdiagnoses not only cause needless long-term distress to patients, they also waste valuable health care resources, as expensive surgery and treatments are often unwarranted and unwanted. Indeed, in England, it has been estimated that the National Health Service could save up to some US$50 billion every year if people were fully engaged in decision-making and actively took ownership of their health.

Key elements highlighted by the research include:

  • Involving patients in decisions about their health improves medical care and saves money;
  • Well-informed patients typically consume far less medicine - many patients who are well informed choose less invasive and less costly treatment options;
  • More care doesn't necessarily mean better care – higher spending on health does not always lead to better quality care for patients or better outcomes (the World Health Organization estimates 20-40 percent spent on health is wasted on inappropriate tests/treatments);
  • Health care may be one of the only fields in which increasing customer satisfaction actually costs less.

The new study comes at a time when a recent analysis by Standard & Poor's has warned a number of countries, including the US and UK, could see their credit ratings downgraded within the next decade if they fail to cut health care costs.

Breaking the silence

The research released today has been undertaken by The Dartmouth Center for Health Care Delivery Science at Dartmouth College, a center of global excellence on delivering better health outcomes at lower cost and pioneer of informed patient choice.

Professor Al Mulley, Director of The Dartmouth Center, led the research and took part in the UK Independent Breast Screening Review:

'Most medical treatments involve choices and trade-offs. For example, screening programs can bring real benefits but also serious harm, such as over-diagnosis.

More than 100 years ago student doctors were told to 'listen to the patient, he is telling you the diagnosis'. Today, the rise in treatment options makes this even more critical, not only to reach a correct medical diagnosis but also to understand fully patients' preferences - and reduce the huge waste in time and money that comes from the delivery of services that patients often neither want nor need.'

Co-author of the study, Professor Glyn Elwyn, a primary medical care physician and Distinguished Research Chair at Cardiff University who is currently Visiting Professor at The Dartmouth Center, added:

'Putting an end to the 'silent' misdiagnosis should be at the heart of efforts to make care more patient-centered. It is a win for patients who get the health care they truly want; and it is a win for doctors who can then be confident that they are delivering the right care, every time, to every patient.

Techniques such as shared decision-making help ensure that both doctor and patient make a sound assessment of the best scientific evidence and that doctors understand patients' personal values and preferences.'

Chris Trimble, Adjunct Professor of Business Administration at The Dartmouth Center for Health Care Delivery Science and the Tuck School of Business, commented:

'Business professionals take the challenge of diagnosing customer wants and needs very seriously. When an executive fails to grasp what his or her customers want, the consequences can be severe – bankruptcy, for example. In contrast, in the health sector, understanding patients' preferences is barely on the agenda.'

A Doctor's Guide to Making a Preference Diagnosis

To make an accurate preference diagnosis, the authors of the study suggest doctors follow a three-step process:

  1. Adopt a mindset of scientific detachment - become aware of the specific factors that frequently lead to bias in making accurate preference diagnoses;
  2. Formulate a provisional preference diagnosis – refer to an evidence base of past patient preferences and treatment choices;
  3. Engage the patient in conversation and deliberation – patient and doctor work together as a team to explore treatment options, help the patient understand the risks and benefits of each, and identify the patient's preferences.


All media enquiries:

Justin Anderson
Email: Justin.Anderson@dartmouth.edu
Tel: +1 6036463661

Shea Drefs
Email: Shea.m.drefs@dartmouth.edu
Tel: +1 6036462255

Al Mulley is Director of the Dartmouth Center for Health Care Delivery Science and Professor of Medicine at the Geisel School of Medicine at Dartmouth, New Hampshire, USA. Professor Mulley was the first International Visiting Fellow to be appointed by The King's Fund, a health policy organization in England.

Co-authors of the research paper are Glyn Elwyn, Distinguished Research Chair at Cardiff University and Visiting Professor at The Dartmouth Center for Health Care Delivery Science and Chris Trimble, Adjunct Professor of Business Administration at The Dartmouth Center for Health Care Delivery Science and at the Tuck School of Business at Dartmouth.

The full BMJ paper Stop the Silent Misdiagnosis: Patients' Preferences Matter can be accessed under embargo at: http://press.psprings.co.uk/bmj/october/misdiagnosis.pdf. URL once embargo lifted: http://www.bmj.com/cgi/doi/10.1136/bmj.e6572

About The Dartmouth Center for Health Care Delivery Science

The Dartmouth Center for Health Care Delivery Science actively supports countries, communities and individuals in taking informed decisions about the most appropriate options to meet their health care needs. It builds on work undertaken over many years by Dartmouth's medical, business and engineering schools to support the delivery of high-quality health services, design and implement information systems, evaluate medical practice, and measure performance and health outcomes. For example, The Dartmouth Atlas of Health Care has documented glaring disparities in medical practice and the cost and quality of health services, inspiring a series of country-led initiatives worldwide (including the NHS Atlas of Variation) to increase effective care, improve clinical decision-making, and rationalize the supply of medical resources.

Founded in 1769, Dartmouth College is a member of the Ivy League group of universities in the US and consistently ranks among the country's top academic institutions. Dartmouth has forged a singular identity for combining commitment to outstanding undergraduate liberal arts and graduate education with distinguished research and scholarship in the arts and sciences. It has three leading professional schools—the Geisel School of Medicine, Thayer School of Engineering, and the Tuck School of Business.