Factors affecting our diagnostic accuracy

“Diagnostics and treatment are interdependent – but diagnostics are:-under-recognised-under-resourced-under-funded Policymakers and funders must prioritise #diagnostics to reduce the diagnostics gap and prevent premature deaths.” –The Lancet, Oct 7, 2021[1] Dear Editor, Nabi et al. analyse the discrepancy between admission diagnosis in emergency and final diagnosis in ward and then make its correlation with the length of hospital stay and mortality in their original article published in September–October 2022 issue of the journal.[2] They make a bar chart of the rate of diagnostic discrepancy amongst various organ systems and discover that at their hospital, such incoherence is the maximum amongst group of certain infections. Moreover, when they compared various organ system diseases, they found that circulatory disorders were the group where such correlation – or the lack of it – was the highest. While describing salient features of their study results, the investigators underscore that the highest discrepancy was seen in myocarditis (62.5%) group of patients. Therefore, as this is the – or one of the – most important findings of the article, let us discuss it hereupon. Viral infections are one of the most common causes of myocarditis.[3] Moreover, such diseases evolve sometimes after admission to a healthcare facility. For example, when a patient experiences chest pain, he presents to a clinic with variable symptoms[4] and after repeated examinations,[5] he may be correctly diagnosed. Under these circumstances, if one physician examines a patient when he has had a different presentation (at emergency department) and later, his symptoms evolve to a different one (in wards), and there is diagnostic discrepancy, we think that it simply represents evolution of the pathological rather than a diagnostic discrepancy in emergency. The study results has a heading – Baseline and clinical characteristics. There the writers highlight that the average length of hospital stay (days) for concordant diagnosis was 5.16 and for discordant lot was 7.05. Here, we want to add that shorter stay of the concordance group may be due to presentation of the patients at a later stage when some (provisional) diagnosis was already made at a peripheral centre. Hence, early discharge of such patients may be there because as now, we have their previous reports available, and we can compare the latest one with the baseline one. At this stage, either presence or its absence may be somewhat an easy task. Moreover, it may not have a relationship with baseline accuracy of diagnostic workup of the assessing physician – one who made a different diagnosis in the emergency department. Although the physicians state under a heading – Materials and Methods – that patients received from other health-care centres after being treated as inpatients were excluded from the study, it is possible that those treated as outpatients were there under study here. Hence, if they have some medical record with them of such a visit, it may have a different effect for making a diagnosis than its absence. In the catchment area of our hospital, poisoning is a common mode of suicide and celphos is the poison which women commonly consume when they decide to end their life. When such patients present at the emergency department, myocarditis is a complication attached to the toxic substance. Here is a case report where a patient developed cardiotoxicity during the course of her admission.[6] Hence, what we may argue is that if markers of cardiac involvement were not there at presentation that may be because it was not there then. Therefore, discrepancy of the diagnosis at certain stages may crop up which indicates known course and association of the pathogenic process. However, if we closely look at the study duration (over nearly 1½ years, from October 2018 to February 2020), it mostly belongs to before the spread of COVID-19 pandemic. Later on during the pandemic, COVID-19 was associated with a 2–3-fold higher risk of myocarditis and unexpectedly, lower rates of heart failure diagnosis: due to presentation of the patients with failure of both the organ systems and one interfering with accurate assessment of the other.[7] Moreover, overdependence on investigations and ignoring the history and physical examination can lead to discrepancy in diagnosis in emergency and medicine ward. Rapid and widespread availability and quick results of some cardiological investigations such as electrocardiographic, cardiac enzymes (CPK MB [Creatine Phosphokinase-MB] and Troponin T), echocardiography (sometimes bedside one), high-resolution computed tomography (CT) thorax, and CT/invasive coronary angiography may suppress our clinical acumen. Next to circulatory disorders come the respiratory disorders where diagnostic discrepancy occurs and amongst the diseases included in the category ARDS tops the list, as the authors mention in the data analysis outcomes. 47% is the frequency with which such discordance was observed. What we want to add is that the syndrome may not be present at admission and may develop only later on in few cases.[8] It is, for this reason, the discrepancy between admission and later assessment at wards may be because now the patient has had a different nature of illness at different points of time. We admit patients to hospital so that we may observe them closely for change in the course of their disease and respond appropriately as and when they develop newer symptoms and signs. It is for this reason a different diagnostic label which may not necessarily indicate something missed and we need to have a wider perspective to include several other possibilities as well. While providing feedback to the emergency team may yield positive results for mutual benefit, what also should be considered is that an illness may alter its course after hospitalisation and we need to follow our patients with utmost care. As a physician, we always need to examine a patient with eyes wide open and rapidly detecting emerging findings may make us to rethink. Our humility to re-examine ourselves is a virtue which we need to deploy more and listening to patients may yield novel ideas. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.