By Dorothy Brooks
When patients present with existing diagnoses or disabilities, clinicians might attribute any symptoms to the existing condition. This is called diagnostic overshadowing, a type of cognitive bias that can cause unnecessary suffering, unsafe care, and adverse events related to missed or delayed diagnoses. Unfortunately, the problem occurs more often among groups already experiencing healthcare disparities.
The Joint Commission (TJC) has taken notice, issuing a Sentinel Event Alert that urges health systems to raise awareness about diagnostic overshadowing, and to take steps to root out the problem.1 Much of the research into diagnostic overshadowing and cited by TJC has occurred in Europe.2,3
However, Lisa Iezzoni, MD, MSc, director of the Mongan Institute for Health Policy at Massachusetts General Hospital in Boston, has spent considerable time interviewing patients with disabilities who have suffered harm because of diagnostic overshadowing. Iezzoni was alerted to the problem when a friend who is disabled with multiple sclerosis (MS) experienced repeated delays in receiving an accurate diagnosis and treatment for cancer. “His healthcare providers just refused to work up symptoms that were screaming out loud that he had cancer,” recalls Iezzoni, who later published an account of this case.4
Eventually, surgeons removed a 15-pound tumor from the friend’s abdomen, about eight months after his symptoms started. “None of the physicians ever said it clearly, but I am sure they thought the symptoms he was having related to the progression of his MS,” Iezzoni says.
Another notable case Iezzoni studied involved a young woman who had sustained a spinal cord injury and used a wheelchair. About three years after the injury, the woman developed abdominal pain and presented to the ED for care. Iezzoni notes physicians attributed the problem to gastroparesis; they thought the issue was the patient’s stomach was not emptying properly, possible a result of her spinal cord injury.
Meanwhile, the woman was losing weight, but the diagnosis did not change much, even after repeated visits to the ED. “The providers kept saying the problem was either bulimia, anorexia, or gastroparesis ... but they didn’t test her for gastroparesis,” Iezzoni recounts.
When the woman’s weight declined to 63 pounds, providers decided to insert a feeding tube, which they needed to perform with X-ray guidance. That is when they found the tumor. The patient had lymphoma. Also, providers finally tested the patient for gastroparesis, which was negative.
While not all instances of diagnostic overshadowing are so dramatic, patients with disabilities tend to agree it is a problem, according to Iezzoni, who also lives with an MS-related disability. When a patient visits an ED for a sprained ankle, and the patient happens to be deaf, the physician might spend most of the time probing all the particulars of the patient’s disability rather than focusing on the chief complaint.
“A lot of people use the ED for primary care problems that they really should go to a primary care provider for. I get that they might be presenting with chronic conditions, and that is going to be an issue that has to be dissected,” Iezzoni observes. “But if someone comes in with an acute complaint, [he or she] needs to be taken seriously, as if they didn’t have their disability.”
Generate the differential diagnosis independently of the disability. Starting there is not the best tactic when patients arrive with urgent problems. Secondly, clinicians should consider whether they have an ableist attitude that leads them to stereotype patients with disabilities or devalue their concerns. While such prejudice is not the same as diagnostic overshadowing, it is easy to see how it can play a role in missed or delayed diagnoses. “It is something I have heard [about] repeatedly, and I have interviewed more than 300 people with different types of disability,” Iezzoni says.
TJC recommends clinicians use an “intersectional framework” when assessing patients in groups that are more at risk of experiencing diagnostic overshadowing. Joe Grubenhoff, MD, director of the diagnostic safety Program at Children’s Hospital Colorado in Aurora, explains how such an approach might work in practice. Consider a patient who arrives appearing intoxicated and the history indicates substance use disorder (SUD). “Maybe this patient is encephalopathic, and he has an underlying medical condition,” Grubenhoff offers.
The intersectional framework approach calls for pausing and recognizing possible existing biases. “You need to check that at the door and go through an appropriate diagnostic evaluation to make sure you are not missing a different medical explanation,” Grubenhoff suggests.
ED leaders can highlight the fact there is a higher risk of cognitive errors when diagnosing specific categories of patients in which providers may be more likely to attribute a patient’s presenting complaint to a pre-existing condition. Further, leaders also can provide guidance about another type of cognitive bias called fundamental attribution error. “That’s where you actually blame the patient for their problem, suggesting it is due to something inherent in their lifestyle or living conditions or a result of their actions,” Grubenhoff says.
Grubenhoff educates by holding hospitalwide collaborative case reviews during which attendees discuss specific cases in a way similar to a morbidity and mortality conference. Grubenhoff encourages colleagues to share cases worth discussing. “The cases have to have elements of both system and cognitive process failures that led to an adverse event,” he explains. “When you look at the literature, it is very rare that cognitive errors occur in isolation from system problems.”
Also, the case has to involve multiple disciplines. For example, there could be multiple subspecialties that were involved in the patient’s care, or there might have been a disconnect between nursing and the medical staff or between respiratory therapy and nursing. Everyone held different perspectives, but no one shared those opinions.
Leaders engaged in work aimed at improving health equity likely already understand many of their concerns are shared by investigators working to improve accuracy with respect to diagnosis.
“There is a huge intersection between the cognitive biases around how we arrive at conclusions and the implicit biases associated with categories of things like race, gender, and sexual orientation,” Grubenhoff says.
Because of these shared interests, Grubenhoff notes his hospital’s manager of diversity, health equity, and inclusion participates in the case review sessions. “He helps us pull out where the intersection is between the systems issues, the equity issues, and the cognitive issues, and how they are playing together,” he says.
While raising awareness about diagnostic overshadowing and other types of bias is an important part of striving for improvement, it is difficult to pin down when such issues have occurred.
“When someone makes a cognitive error in their diagnostic process, there is not an obvious discrete event that people can track through an electronic medical record or something like that. You have to create ways to identify those systematically that are not dependent on passive reporting,” Grubenhoff explains.
One way to approach the issue is to study patients who make repeated visits. “We look at cases where patients are seen in our ED or our urgent care system, are discharged, and then return within 10 days,” Grubenhoff says. “If the diagnosis seems to have changed and we got it wrong on the first pass, then we do a deep dive.”
Iezzoni concurs with this approach. “If an ED is already doing this, then I would simply add another data point that they should use in evaluating such cases, and that is whether the person has a disability,” she says. While there is no accreditation or regulatory requirement for EDs to evaluate their diagnostic performance, Grubenhoff believes TJC’s recommendation may be a signal this could change.
“TJC is probably starting to recognize that they are going to have to start addressing this space in terms of having requirements that focus on diagnostic safety,” he says.
REFERENCES
1. The Joint Commission. Diagnostic overshadowing among groups experiencing health disparities. June 22, 2022.
2. Blair J. Diagnostic overshadowing: See beyond the diagnosis. British Journal of Family Medicine.
January/February 2017.
3. Jones S, Howard L, Thornicroft G. Diagnostic overshadowing: Worst physical health care for people with mental illness. Acta Psychiatr Scand 2008;118:169-171.
4. Iezzoni LI. Dangers of diagnostic overshadowing. N Engl J Med 2019;380:2092-2093.
When patients present with existing diagnoses or disabilities, clinicians might attribute any symptoms to the existing condition. This is called diagnostic overshadowing, a type of cognitive bias that can cause unnecessary suffering, unsafe care, and adverse events related to missed or delayed diagnoses. Unfortunately, the problem occurs more often among groups already experiencing healthcare disparities.
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