Kostopoulou Olga, Devereaux-Walsh Charlotte, Delaney Brendan C
Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK.
Med Decis Making. 2009 May-Jun;29(3):282-90. doi: 10.1177/0272989X08327493. Epub 2009 Mar 6.
Delays in diagnosing celiac disease average 13 years. We aimed to identify reasons for misdiagnosis in family medicine.
During a larger study on diagnosis, a scenario describing a 30-year-old female with 3-month abdominal pain, diarrhea, and microcytic anemia consistent with celiac disease was presented on a computer to 84 family physicians. Their information gathering and diagnoses were recorded. Fifty physicians misdiagnosed, and 38 of these took part in "stimulated recall'': they were asked to recall their hypotheses and inferences step by step, aided by a record of their information gathering. They were unaware of the misdiagnosis.
Transcripts were analyzed to identify whether celiac disease was mentioned and how information was interpreted. Two raters independently assessed information interpretation against the published evidence (kappa = 0.85).
Physicians did not change their diagnoses during stimulated recall. Only 10 physicians mentioned celiac disease as a hypothesis (26%). "Diarrhea'' and "pain relief by defecation,'' consistent with both celiac disease and irritable bowel syndrome (IBS), were only linked to IBS. "Absence of weight loss'' led to rejecting celiac disease, although weight loss is characteristic of advanced disease. A complete blood count was requested as a routine test and not specifically for celiac disease. Thus, the unexpected result of "microcytic anemia,'' inconsistent with IBS, did not trigger the correct diagnosis.
Most physicians never considered celiac disease. Information inconsistent with the favorite IBS diagnosis was overlooked. Reviewing the case did not prompt physicians to consider celiac disease, re-evaluate the evidence, or rethink the IBS diagnosis.
乳糜泻的诊断平均延误13年。我们旨在确定家庭医学中误诊的原因。
在一项关于诊断的大型研究中，通过计算机向84位家庭医生展示了一个病例，该病例描述了一名30岁女性，有3个月的腹痛、腹泻和与乳糜泻相符的小细胞性贫血。记录了他们的信息收集情况和诊断结果。50位医生误诊，其中38位参与了“激发式回忆”：在其信息收集记录的帮助下，要求他们逐步回忆自己的假设和推理过程。他们当时并不知道自己误诊了。
对记录文本进行分析，以确定是否提及乳糜泻以及信息是如何解读的。两名评分者根据已发表的证据独立评估信息解读情况（kappa = 0.85）。
在激发式回忆过程中，医生们没有改变他们的诊断。只有10位医生将乳糜泻作为一种假设提及（26%）。与乳糜泻和肠易激综合征（IBS）均相符的“腹泻”和“排便后疼痛缓解”仅与IBS相关联。“没有体重减轻”导致排除乳糜泻，尽管体重减轻是晚期疾病的特征。血常规作为一项常规检查被要求进行，而不是专门针对乳糜泻。因此，与IBS不符的“小细胞性贫血”这一意外结果并未引发正确的诊断。
大多数医生从未考虑过乳糜泻。与最常诊断的IBS不符的信息被忽视了。回顾该病例并未促使医生考虑乳糜泻、重新评估证据或重新思考IBS的诊断。
