Medical misdiagnosis: What you need to know

Early this year, Paul Kabira went to a private hospital for proper diagnosis after having a persistent cough. After a number of tests, and given a clean bill of health, he was given antibiotics to suppress the cough. Kabira religiously took the five-day medical and experienced temporary relief. Two weeks later, Kabira complained of pain in the chest. When he was taken to another medical facility it emerged that he was developing acute pneumonia. Unfortunately, they could not treat him immediately because the doctors felt his body needed to be weaned off the antibiotics the first hospital had given him before starting a new line of medication.

For Kabira, he was lucky he sought a second opinion, as others are not lucky enough to do so.

Diagnosis literally means identifying the nature of an illness or problem by examining the symptoms a patient presents. Misdiagnosis or failed diagnosis, therefore, implies that a diagnosis was made but not for the particular ailment a person has.

In Uganda, according to Dr Vincent Bakyenga, a member of the Uganda Healthcare Federation, the level of misdiagnosis is five per cent but this is lower in developed countries because they have better equipment.

“Misdiagnosis comes with litigation so the health workers are usually careful when assessing the facts in order to come up to a right conclusion. When a patient goes to see a doctor for a particular illness, the health workers collects three kinds of facts which are the history, physical examination and diagnostic tests,” says Dr Bakyenga.

The historical facts include when the person developed the problem, whether it is present in their family or how they have always dealt with it and this contributes up to 70 per cent of the diagnosis. Here, Dr Bakyenga says the patient must be very careful to give the exact information needed by the doctor for proper diagnosis.

He says, “the physical examination is important and should not be limited to only one part of the body that has a problem. It should be a thorough examination of head to toe to ensure the exact cause of the problem. For instance, a person may complain to have a sight problem yet the cause may be due to diabetes.”

The physical examination contributes 20 per cent of the diagnosis and the doctor comes up with two or three more likely illnesses depending on the theoretical ruling made by the doctor and these wait to be confirmed or eliminated with tests.

The diagnostic tests are dependent on the first two examinations and are directed towards confirming or eliminating some of the likely illnesses they contribute 10 per cent of the diagnosis. These include the baseline (chest x-ray and heart for developed countries, Complete Blood Count and Malaria test in case of a fever) and the specific tests depending on the likely illnesses the doctor came up with.

With the three tests, the health worker should be able to come up with a conclusion known as a diagnosis. However, sometimes even the diagnostic tests may not be definitive, depending on the health worker’s qualification and experience in a particular disease.

“Sometimes even the diagnostic tests may not be definitive depending on the type of illness. For example, the mad cow disease can only be confirmed after the death of a person when an autopsy is done,” Dr Bakyenga cites.

Causes of misdiognosis

The time dedicated for history taking is sometimes abused by the patients when a patient just rings a doctor on phone instead of going to see the doctor physically. Some patients lie about their age; do not say they are sexually active (for sexual health problems).

According to Prof Pius Okong, the chairperson Uganda Health Services Commission, inability to perform all the necessary tests leads to misdiagnosis because the tests are very expensive.

“Inadequate equipment to do the necessary tests is another pointer to misdiagnosis in most health facilities in Uganda and this prompts doctors to guess depending on the symptoms. In the places where the equipment is available, the tests are too expensive for the poor people to afford,” says Prof Okong.

Failure to follow instructions, Prof Okong adds, “is another cause for misdiagnosis. Take the example of a person who suspects to have diabetes. They are not supposed to eat before the tests and if they do, they will test to have diabetes because of the high sugar levels in the food they have eaten.”
A misdiagnosis may also occur depending on the health workers’ academic qualification. If he is not well learned, he is likely to fail to interpret the results of the examination and thus a failed diagnosis. Also if he is not experienced about a particular kind of illness, he may not be sure what it is or how to handle unless he has seen a number of people with a similar condition.

Other reasons may include patient’s delay to seeking medical advice, reagents used; the state of the sample (biopsy) may have stayed long and could not give clear results especially for patients that stay upcountry.

Caution

Dr Bakyenga remarks that it is important for doctors to maintain patient records and the patient has a right to ask from the doctor for copies of these records because it is their life at stake.

“Ethically, a doctor must do no harm but the records can save him in cases of misdiagnosis that caused harm because he must defend himself with written notes about the patient and why he chose that treatment option,” he says.

If there was misdiagnosis and there was harm to the patient, the patient has the right to appeal through the Uganda Medical and Dental Practitioners’ Council, Uganda Healthcare Federation, Allied Health Professionals’ Council, Uganda Nurses and Midwifery council or the court.

Prof Okong says, “before making an appeal, the patient should be vigilant to know whether it was not a system failure (for example the over exposure by the faulty radio machine at the Cancer Institute); if he followed doctors’ instructions because there are cases of harm caused by the patient not following instructions.”

The responsibility of the doctor stops at the prescription and if the patient did not take the medicines as instructed, they are to blame.
The council then summons the doctor but also discuss what results another doctor with the same experience, training and resources come up with.

Categories of misdiagnosis

These are some of the instances that constitute misdiagnosis;

•Intentional misdiagnosis although rare according to Dr Bakyenga, may happen because the health worker intends to misdiagnose someone for his own selfish benefits. For example, if he recommends surgery for a minor problem that would be healed with antibiotics.

•Misdiagnosis due to incompetence may arise due to the health worker’s lack of training and experience.

•Accidental misdiagnosis such as swapped operations may arise because the health worker is overworked and was fatigued depending on the number of patients he sees in a day.

•System failure may occur such as the case of radiotherapy machine at the cancer institute. There could have been over exposure to some patients since the machine was old.

•Differential diagnosis occurs because there are illnesses that have similar symptoms and choosing the most likely may cause misdiagnosis if there are no testing equipment to confirm.
How to manage errors

Have a good record keeping system that may be electronic or manual but ensure it is easy to read and find but hard to alter.

Monitor the quality of your clinicians and the results from your machines to ensure that they are giving the right results.

Have a malpractice insurance for the health workers so that in case of an error, it is not the hospital or the individual to pay and instead the insurance.

Be part of a monitoring organisation that you are accountable to so as to share experience in case of strange and difficult to diagnose conditions.
Patients should never take the diagnosis of one doctor especially when it involves an operation. They should always confirm with another test at another health worker.

Have a good relationship with the doctor and have frequent visits to the health centre. This will enable your doctor notice any changes in your health even when you do not tell him.

Mostly misdiagnosed health conditions include cancers because most health facilities do not have the testing capabilities for them. Other includes infections in the kidney, pneumonia, meningitis, typhoid, skin infections, ectopic pregnancies as tumors and others.

Experience: A second opinion in India saved my life

Jane* could not get proper diagnosis for her cancer type until she was taken to India.

I had a stomach upset, bloating and constipation all the time. When I went to Nsambya hospital, the doctors said I had a bacterial infection and I was given treatment but the problem did not go away.

A month later, I went to a Chinese clinic in Kabalagala but there was a Ugandan doctor who, after the blood tests said I had worms which caused the discomfort in my stomach. I took the medication he prescribed for me but there was no change.

In August, a friend told me of a doctor on Kira Road in Kampala. I showed the doctor my previous medical forms and he said it was a wrong diagnosis. He said he did not want to scare me but suspected I had cancer. He did the CA 125 test tumour marker, an ultra sound, CT scan and blood tests that cost me only Shs50,000 but the results did not give any indication of cancer.

The doctor insisted there should be something close to a cancer so he referred me to Dr Twaha Mutyaba, a gynaecologist who palpated my stomach and felt a mass in my right lower abdomen. He used a mobile scanner and I saw a mass floating.

He suggested this mass be removed as soon as possible before it could attach somewhere in the body. I was immediately admitted at Kibuli hospital and was operated on the next day. The doctor removed the hanging mass but was not sure what it was, so a sample was taken to some laboratories in Kampala but they could not identify what I was suffering from.

I was discharged from Kibuli hospital after a week but the doctors recommended that I do a PET CT scan which was unavailable in East Africa.

I had to choose between going to South Africa, Israel or India. I chose to go to BLK specialist hospital in New Delhi in India for proper diagnosis.

I was admitted right away because I still had a fresh wound from the surgery. The next day, I underwent the scan which showed I had ovarian cancer at stage three.
The cancer cells had covered my ovary. I am still undergoing treatment but I cannot believe that I had to seek proper diagnosis on another continent. ---As told to Beatrice Nakibuuka

*Name changed to protect patient’s identity.