A response to the Agency for Healthcare Research and Quality (AHRQ) Systematic Review on ER Misdiagnosis
It’s 2 AM, and you aren’t able to sleep because of pain in your chest. Is it a heart attack? Was it something you ate? Is it a muscle spasm? Imagine another scenario: you have a history of high blood pressure, and you can’t afford your medications this month. You measure your blood pressure at home, and the cuff reads extremely elevated. In both of these cases, you will consider seeking medical attention and likely end up in a hospital’s Emergency Department (ED). Understandably, you will want your pain treated, your blood pressure controlled, and to go on living a happy and healthy life.
The reality, however, is that medicine and physicians have limits and that even the most skilled diagnostician will be unable to fully solve the puzzle 100% of the time in a single ED visit. If you’ve read recent headlines, the AHRQ just released a report with a takeaway that millions of Americans suffer each year due to “misdiagnosis.” Besides the fact that the data drawn from the report has statistical flaws, the clickbait headlines that ensued misrepresent the data in the report, as well as the role of Emergency Medicine in the healthcare system. The role of the ED is not to give you a clean bill of health, rather, it is to make sure you do not have an emergency that requires immediate intervention. Often, the recommended follow-up by an Emergency Physician gives the follow-up caregiver the value of the “retrospectivescope” (aka “time”) to re-evaluate the data gathered in the ED along with the course of the patient’s symptoms or disease process.
Here is an oversimplified behind-the-scenes look into how a physician in Emergency Medicine (EM) is trained. For patients with chest pain, we take a focused history. First, we form a “differential diagnosis” that takes into consideration the most common deadly causes of chest pain: heart attack, aortic dissection, blood clots in the lungs, etc. There may be dozens of causes of chest pain, but emergency physicians are trained to rule out the most serious. We then risk stratify and run tests based on this list. In straightforward cases, we make a diagnosis: blood clot. In other cases, the tests we send are normal, and no concrete diagnosis is made.
We recognize the need for further investigation and, based on the history, decide whether this needs to be done in the hospital or can safely be done as an outpatient. This does not mean that the patient was “misdiagnosed,” and it also doesn’t mean that there is no serious cause of the chest pain. Rather, a workup is ongoing. It is incredibly frustrating for both patients and physicians when a diagnosis is not immediate, and symptoms persist. However, it is our job as Emergency physicians to set realistic goals, communicate a follow-up plan, and relay to the patient when to come back for an evaluation.
The field of Emergency Medicine has a dynamic history. Prior to the 1960s, the traditional Emergency Room (ER) was a small room in a hospital basement called “the pit” staffed by physicians in training and students. Over the course of the 20th century, the American College of Emergency Physicians (ACEP) was formed, originally comprising eight physicians. The specialty of Emergency Medicine evolved with the intention to focus on the most life-threatening, severe illnesses and injuries (1,2). Today, we are no longer a room but an entire department, and instead of just serving the sickest of the sick, we are now the safety net for millions of Americans with both urgent and non-urgent medical issues. Part of this is because roughly 1 in 4 Americans do not have a primary care doctor (3). We see the chest pain patient next to the elevated blood pressure patient next to the nosebleed patient next to the gunshot victim. We are the masters of switching gears.
Emergency medicine has evolved from the eight physicians of ACEP to multiple professional societies and thousands of physicians. Together they have responded to the AHRQ with a multi-organizational letter: “While it is clear that EM, just as all specialties, can improve, we have reviewed the materials available to us and identified multiple findings that are misleading, incorrectly interpreted, and, in several cases, incorrect” (4). If you wake up with chest pain or are concerned about your health, don’t be discouraged from visiting the ED due to headlines about misdiagnosis of serious conditions. Despite facing multiple challenges in an imperfect system, Emergency physicians continually strive to serve you better, communicate better, be humble and realistic, and ultimately connect you to the care you need.
Dr. Christine Collins
Dr. Christine Collins is an Emergency Medicine resident at Cooper University Hospital in Camden, NJ. Following in the footsteps of Dr. Mazzarelli(Dr. Mazz), she just completed a one month internship on The Michael Smerconish Program.
Dr. Anthony Mazzarelli
Anthony Mazzarelli, MD, JD, MBE is Co-President and CEO of Cooper University Health Care and a practicing Emergency Medicine physician. He is co-author of Wonder Drug: Seven Scientific-Proven Ways That Serving Others is the Best Medicine for Yourself.
- Suter RE. Emergency medicine in the United States: a systemic review. World J Emerg Med. 2012;3(1):5-10. doi: 10.5847/wjem.j.issn.1920-8642.2012.01.001. PMID: 25215031; PMCID: PMC4129827.
- Jason Wilson. “24 7 365.” YouTube, 15 Jan. 2017, www.youtube.com/watch?v=ceMwsvV1_xc.
- Levine DM, Linder JA, Landon BE. Characteristics of Americans With Primary Care and Changes Over Time, 2002-2015. JAMA Intern Med. 2020;180(3):463–466. doi:10.1001/jamainternmed.2019.6282
- Multi-organizational letter regarding AHRQ report on diagnostic errors … (n.d.). Retrieved January 2, 2023, from https://www.acep.org/globalassets/sites/acep/media/medical-legal/multi-organizational-letter-regarding-ahrq-report-on-diagnostic-errors-in-the-emergency-department—december-14-2022.pdf?trk=public_post_comment-text