National Malaria Technical Director and Professor of Paediatrics at University of Ilorin and University of Ilorin Teaching Hospital, Kwara State, Prof. Olugbenga Mokuolu talks to LARA ADEJORO about misdiagnoses and how to prevent them
What is a misdiagnosis?
A misdiagnosis, as the name suggests, is a diagnosis that has been missed. This means that there is an inability to identify the real problem, which can result from several factors. This often stems from the type of information available to you; either the information provided by the patient or the information from the laboratory procedure was not sufficient to make an accurate diagnosis.
Sometimes it can also be due to knowledge issues; we have a chain of hierarchy and specializations so if you show up to someone and it might not be their area of strength, they might have an idea of the problem but they don’t don’t know the diagnosis. This is because there might be some technical aspects of this diagnosis which are beyond the competence of this person; it doesn’t mean the person isn’t competent, but you can’t know everything.
Based on this, you could miss the diagnosis. Then the conditions mimic each other a lot. Several pathological conditions share overlapping symptoms. There may be a masquerade of conditions wearing the clothes of a different condition, and one will be deceived into making the wrong diagnosis.
What are the reasons for a significant misdiagnosis?
It shouldn’t be too substantial because, globally, in medicine, we are used to what I would call a diagnostic algorithm. In other words, you are going through a process.
Typically, when a doctor asks questions such as name, address, age, gender, onset of illness, location of problem, character of problem, whether he comes and goes (intermittent), etc., and the doctor navigates through a diagnostic algorithm in their mind.
Each question serves to understand what the problem may be. You can then understand that if something is wrong with the algorithm you are using at any given time, it can lead to misdiagnosis.
Again, this faulty algorithm at this time is not entirely due to your intelligence or your excellence. For example, if I am allowed to recognize someone in a critical situation, I may not be able to put my finger on the exact diagnosis. If I recognize that someone is in a critical case, I am allowed to wonder what is required for that specific diagnosis or what is required for optimal management. If I take these next steps, I haven’t done anything professionally wrong.
Thus, a misdiagnosis results from a combination of the person’s experience, the information available to them, the tools available to validate the suspected condition, and how that condition expressed itself at the time.
If we’re talking about substantial misdiagnosis, it tends to happen if we don’t go to the right places. For example, people may know what a drug does, but they may not have been trained in how to recognize that condition. So if you don’t appreciate your limit, your knowledge of the use of the drug does not equal your understanding of the diagnosis.
Besides fever, what other health conditions are most commonly misdiagnosed?
Almost any health condition can be misdiagnosed. The reason for this is that some are very dramatic in the way they show themselves, and others are hidden, only to appear later. I can’t think of any health condition that can’t be misdiagnosed. If you don’t do the right thing, you’re going to misdiagnose anything.
Headaches are common, and they are a symptom of anything; it can be an eye problem, a strain or a brain tumour.
From our training, each condition will have a differential diagnosis, which means that at any time there is an indicator of one to several possibilities, and you start to rule them out until you make the final diagnosis. . What happens is that due to the experience of the person, the interval between when I see someone and when I make a definitive diagnosis may differ; sometimes it can feel like seconds, and other times I have to go through multiple processes.
Can multiple diagnoses of a health condition at different health facilities help determine the accuracy of the health condition?
Generally speaking, you do not need to do multiple diagnoses or multiple tests to be sure of the diagnosis. The responsibility for taking a test rests with the person asking you to take the test, ie your clinician. Your clinician interprets a test and decides if what he has represents what he expects or has reason to believe the test was performed correctly, and therefore the clinician will go with the test results.
Sometimes patients have their own ideas. We know that sometimes patients buy tests, especially if they expect a particular type of result, but that’s the patient’s problem. We don’t expect people to order tests for themselves, but we have no control over this. If you say someone has sickle cell disease and they don’t know their parents might have it, there’s always a tendency to say something was wrong with the test. If the patient is initiating this movement, they are doing so because they have specific concerns and are looking for a different response, but most of the time it is not necessary. If there is any doubt about the benefit of a diagnosis, it is your clinician’s prerogative to make that judgment. There are certain types of tests for which you need a certain degree of skill. it’s not only in each test that you put something in the machine; there are tests that involve your superior. A patient should not order a test and go from laboratory to laboratory repeating the same test to validate a test.
Sometimes people who have had a test performed may not be able to give all aspects of the diagnosis because the diagnosis is not limited to that test.
How can we reduce and prevent the incidence of misdiagnosis?
Don’t go to the wrong people. If you talk to the right people, they will guide you through the system. The right person is the one who can see you, acknowledge the situation with you, and determine if they know what the problem is. If the person does not know, they refer you to the next appropriate level of personnel who can make the diagnosis. Nothing wrong if you are guided through the system along such a trail. This is the basis of medical referral in the health system.
We also need to understand that even in the best places, diagnoses of some conditions are not straightforward due to the nature of the condition and what is needed to make that diagnosis. There are also conditions that we do not have the capacity to produce quickly and regularly.
Earlier I said that fever can be due to malaria and caused by bacteria or virus.
In almost all cases, diagnosing a viral infection is a bit tricky, but quite often most viral infections are self-limiting. So we have to be aware of going through this algorithm that I said in order for us to do what is always expected.
So, some conditions have very simple tests that are accessible everywhere. If someone comes with a fever, we can check the blood, but we can’t tell if it’s malaria or not. If that test comes back negative, then you know it’s not malaria, so you wonder what else it could be. Then there are other types of tests at this stage that are indicated; you may need to do a blood culture, if there are bacteria in the blood the culture will identify them, but it may take a few days before the result is published.
How does quackery contribute to misdiagnosis in the country?
It’s the mother of misdiagnosis, because quackery implies you’re not properly trained for what you’re trying to do. We need an increasingly strict enforcement system to make sure we don’t allow quackery in the medical space.
I must, however, point out that some people may not have started out as properly trained personnel like the exclusive patient vendors, but the government has gone a step further, that even for those, efforts are being made to engage them and give them basic training so that the service they are trying to render at this level can be channeled positively.
So it may not be everyone we can hunt, but we can engage and require everyone who participates to engage in the best practices for their level. We need to understand that there are levels of service delivery.
At the community level, our focus is to ensure that community members or the health worker who could be a trained volunteer are able to perform a basic characterization of any patient and able to recognize a patient at risk of dying or whose condition needs something beyond what they can provide at this community level.
If a patient is misdiagnosed, what are the processes involved in reporting the case to the appropriate authority and what are the penalties incurred?
Misdiagnosis is not an offense, primarily. It will only be an offense if you are not supposed to be there.
Even if you go to court, what the court wants to establish is whether you acted appropriately according to your level of competence in the given context at that time. However, we must fight against quackery. We need to rationalize what a medical professional can do. If you are a laboratory specialist, you work in your laboratory as an individual within the system in which you are employed; if you are a pharmacist, you also have your space and some basic care to offer for simple ailments.
Community pharmacists can diagnose some basic things like fever and diarrhea if they have been trained. They may be able to recognize these conditions and offer intervention, but they are not the right place to diagnose more complex medical issues.
Over-the-counter drugs assume that people will be able to buy drugs for simple things. A clinician must also learn to work with other health workers to get the best out of each for the benefit of the patient.
Everyone, stay in your lane, do what you’re supposed to do, and do what you’re trained to do. Everyone matters and everyone offers unique services, but the problem comes when we don’t stay in our lane.