When Mistakes Are Made

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February 22, 2006

Why Doctors So Often Get It Wrong

By DAVID LEONHARDT

ATLANTA

ON a weekend day a few years ago, the parents of a 4-year-old boy from rural

Georgia brought him to a children's hospital here in north Atlanta. The family

had already been through a lot. Their son had been sick for months, with fevers

that just would not go away.

The doctors on weekend duty ordered blood tests, which showed that the boy had

leukemia. There were a few things about his condition that didn't add up, like

the light brown spots on the skin, but the doctors still scheduled a strong

course of chemotherapy to start on Monday afternoon. Time, after all, was their

enemy.

Bergsagel, a soft-spoken senior oncologist, remembers arriving at the

hospital on Monday morning and having a pile of other cases to get through. He

was also bothered by the skin spots, but he agreed that the blood test was clear

enough. The boy had leukemia.

" Once you start down one of these clinical pathways, " Dr. Bergsagel said, " it's

very hard to step off. "

What the doctors didn't know was that the boy had a rare form of the disease

that chemotherapy does not cure. It makes the symptoms go away for a month or

so, but then they return. Worst of all, each round of chemotherapy would bring a

serious risk of death, since he was already so weak.

With all the tools available to modern medicine ? the blood tests and M.R.I.'s

and endoscopes ? you might think that misdiagnosis has become a rare thing. But

you would be wrong. Studies of autopsies have shown that doctors seriously

misdiagnose fatal illnesses about 20 percent of the time. So millions of

patients are being treated for the wrong disease.

As shocking as that is, the more astonishing fact may be that the rate has not

really changed since the 1930's. " No improvement! " was how an article in the

normally exclamation-free Journal of the American Medical Association summarized

the situation.

This is the richest country in the world ? one where one-seventh of the economy

is devoted to health care ? and yet misdiagnosis is killing thousands of

Americans every year.

How can this be happening? And how is it not a source of national outrage?

A BIG part of the answer is that all of the other medical progress we have made

has distracted us from the misdiagnosis crisis.

Any number of diseases that were death sentences just 50 years ago ? like

childhood leukemia ? are often manageable today, thanks to good work done by

people like Dr. Bergsagel. The brightly painted pediatric clinic where he

practices is a pretty inspiring place on most days, because it's just a detour

on the way toward a long, healthy life for four out of five leukemia patients

who come here.

But we still could be doing a lot better. Under the current medical system,

doctors, nurses, lab technicians and hospital executives are not actually paid

to come up with the right diagnosis. They are paid to perform tests and to do

surgery and to dispense drugs.

There is no bonus for curing someone and no penalty for failing, except when the

mistakes rise to the level of malpractice. So even though doctors can have the

best intentions, they have little economic incentive to spend time

double-checking their instincts, and hospitals have little incentive to give

them the tools to do so.

" You get what you pay for, " Mark B. McClellan, who runs Medicare and Medicaid,

told me. " And we ought to be paying for better quality. "

There are some bits of good news here. Dr. McClellan has set up small

pay-for-performance programs in Medicare, and a few insurers are also

experimenting. But it isn't nearly a big enough push. We just are not using the

power of incentives to save lives. For a politician looking to make the

often-bloodless debate over health care come alive, this is a huge opportunity.

ph Britto, a former intensive-care doctor, likes to compare medicine's

attitude toward mistakes with the airline industry's. At the insistence of

pilots, who have the ultimate incentive not to mess up, airlines have studied

their errors and nearly eliminated crashes.

" Unlike pilots, " Dr. Britto said, " doctors don't go down with their planes. "

Dr. Britto was working at a London hospital in 1999 when doctors diagnosed

chicken pox in a little girl named Isabel Maude. Only when her organs began

shutting down did her doctors realize that she had a potentially fatal

flesh-eating infection. Isabel's father, , was so shaken by the experience

that he quit his finance job and founded a company ? named after his daughter,

who is a healthy 10-year-old today ? to fight misdiagnosis.

The company sells software that allows doctors to type in a patient's symptoms

and, in response, spits out a list of possible causes. It does not replace

doctors, but makes sure they can consider some unobvious possibilities that they

may not have seen since medical school. Dr. Britto is a top executive.

Not long after the founding of Isabel Healthcare, Dr. Bergsagel in Atlanta

stumbled across an article about it and asked to be one of the beta testers. So

on that Monday morning, when he couldn't get the inconsistencies in the boy's

case out of his mind, he sat down at a computer in a little white room, behind a

nurse's station, and entered the symptoms.

Near the top of Isabel's list was a rare form of leukemia that Dr. Bergsagel had

never seen before ? and that often causes brown skin spots. " It was very much a

Eureka moment, " he said.

There is no happy ending to the story, because this leukemia has much longer

odds than more common kinds. But the boy was spared the misery of pointless

chemotherapy and was instead given the only chance he had, a bone marrow

transplant. He lived another year and a half.

Today, Dr. Bergsagel uses Isabel a few times a month. The company continues to

give him free access. But his colleagues at Children's Healthcare of Atlanta

can't use it. The hospital has not bought the service, which costs $80,000 a

year for a typical hospital (and $750 for an individual doctor).

Clearly, misdiagnosis costs far more than that. But in the current health care

system, hospitals have no way to recoup money they spend on programs like

Isabel.

We patients, on the other hand, foot the bill for all those wasted procedures

and pointless drugs. So we keep getting them. Does that make any sense?

E-mail: leonhardt@...

Copyright 2006The New York Times Company