BMJ Qual Saf 21:641-648 doi:10.1136/bmjqs-2011-000541
  • Original research

Challenges of making a diagnosis in the outpatient setting: a multi-site survey of primary care physicians

  1. Hardeep Singh6
  1. 1Division of General Internal Medicine, University of California, San Francisco, San Francisco, California, USA
  2. 2Center for Vulnerable Populations, San Francisco General Hospital, University of California, San Francisco, San Francisco, California, USA
  3. 3Kaiser Permanente, Oakland, California, USA
  4. 4The Permanente Federation at Kaiser-Permanente, Oakland, California, USA
  5. 5University of Houston, Houston, Texas, USA
  6. 6Houston VA HSR&D Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
  1. Correspondence to Dr Urmimala Sarkar, Department of Medicine, SFGH Division of General Internal Medicine, University of California, San Francisco, Box 1364, 1001 Potrero, Bldg 10, Floor 3, Ward 13, San Francisco, CA 94143-1364, USA; usarkar{at}
  1. Contributors US developed the analysis plan, oversaw quantitative analysis and wrote the first draft. DB conceived the study, oversaw data collection, owns the data and provided intellectual contribution in editing the manuscript. WS owns the data and provided intellectual contribution in editing the manuscript. AL conducted literature review and assisted with drafting manuscript. CS and NJ conducted quantitative analysis. TG and ANDM conducted qualitative analysis. HS developed the analysis plan, oversaw qualitative analysis and provided intellectual contribution in editing the manuscript.

  • Accepted 20 April 2012
  • Published Online First 23 May 2012


Background Although misdiagnosis in the outpatient setting leads to significant patient harm and wasted resources, it is not well studied. The authors surveyed primary care physicians (PCPs) about barriers to timely diagnosis in the outpatient setting and assessed their perceptions of diagnostic difficulty.

Methods Surveys of PCPs practicing in an integrated health system across 10 geographically dispersed states in 2005. The survey elicited information on key cognitive failures (including in clinical knowledge or judgement) for a specific case, and solicited strategies for reducing diagnostic delays. Content analysis was used to categorise cognitive failures and strategies for improvement. The authors examined the extent and predictors of diagnostic difficulty, defined as reporting >5% patients difficult to diagnose.

Results Of 1817 physicians surveyed, 1054 (58%) responded; 848 (80%) respondents primarily practiced in outpatient settings and had an assigned patient panel (inclusion sample). Inadequate knowledge (19.9%) was the most commonly reported cognitive factor. Half reported >5% of their patients were difficult to diagnose; more experienced physicians reported less diagnostic difficulty. In adjusted analyses, problems with information processing (information availability and time to review it) and the referral process were associated with greater diagnostic difficulty. Strategies for improvement most commonly involved workload issues (panel size, non-visit tasks).

Conclusions PCPs report a variety of reasons for diagnostic difficulties in primary care practice. In this study, knowledge gaps appear to be a prominent concern. Interventions that address these gaps as well as practice level issues such as time to process diagnostic information and better subspecialty input may reduce diagnostic difficulties in primary care.


  • Funding Dr Sarkar is supported by the Agency for Healthcare Research and Quality K08 HS017594. Dr. Singh is supported by an NIH K23 career development award (K23CA125585), and in part by the Houston VA HSR&D Center of Excellence (HFP90-020). Manuscript contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH or any of the other funders. None of the funders had any role in design and conduct of the study; collection, management, analysis or interpretation of the data; or preparation, review or approval of the manuscript.

  • Competing interests None.

  • Ethics approval University of California, San Francisco.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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