The National Malaria Technical Director and Professor of Paediatrics at the University of Ilorin and Ilorin Teaching Hospital, Kwara State, Prof Olugbenga Mokuolu, speaks with LARA ADEJORO on misdiagnosis and how to prevent it

What is a misdiagnosis?

A misdiagnosis, just as the name says, is a diagnosis that was missed. This means there is a failure to identify the real problem, which can result from several factors. It often arises from the type of information at your disposal; either the information the patient provided or the information from the laboratory procedure was not sufficient for an accurate diagnosis.

Sometimes, it could also be because of knowledge issues; we have a chain of hierarchy and specialisations, so if you are presenting to someone and maybe it is not that person's area of strength, they may have an idea about the problem but not know the diagnosis. This is because there could be certain technicalities about that diagnosis that are not within the competence of that individual; it doesn't mean the person is not competent, but you can't know everything.

Based on that, you could miss the diagnosis. Then, conditions mimic each other a lot. Several disease conditions share overlapping symptoms. There can be a masquerading of conditions wearing the apparel of a different condition, and one will be deceived to make the wrong diagnosis.

What are the reasons for substantial misdiagnosis?

It should not be too substantial because, overall, in medicine, we are used to something I want to call an algorithm for diagnosis. That is, you walk through a process.

Typically, when a doctor is asking questions like about name, address, age, gender, the onset of illness, location of the problem, character of the problem, whether it goes and comes (intermittent), etc., and the doctor is navigating through an algorithm for diagnosis in their mind.

Each question serves a purpose in understanding what the problem can be. You can then understand that if anything is wrong with the algorithm you are using at a point in time, it can result in misdiagnosis.

Again, that flawed algorithm at that point in time is not all down to your brilliance or excellence. For instance, if I am allowed to recognise somebody in a critical situation, I may not be able to put my finger on the exact diagnosis. If I recognise that somebody is in a crucial case, I'm allowed to ask myself what is required for this specific diagnosis or what is required for optimum care. If I take those next steps, I've done nothing wrong professionally.

So misdiagnosis results from a combination of the person's experience, the information at the person's disposal, the tools available to validate the suspected condition, and how that condition has expressed itself at that point in time.

If we talk about substantial misdiagnosis, that tends to occur if we don't go to the right places. For instance, people might know what a drug does, but they might not have been trained on how to recognise that condition. So, if you don't appreciate your limit, your knowledge of the use of the drug is not equal to your understanding of the diagnosis.

Apart from the fever, what other health conditions are mostly misdiagnosed?

Almost any health condition can be misdiagnosed. The reason is that some are very dramatic in the way they show themselves, and others are hidden, only to show up at a later stage. I can't think of any health condition that can't be misdiagnosed. If you don't do the right thing, you will misdiagnose anything.

Headaches are common, and they're a symptom of anything; it can be an eye problem, it can be tension, or it can be a tumor in the brain.

From our training, every condition will have a differential diagnosis, meaning that at any point in time, there is a pointer of one to several possibilities, and you begin to knock them off until you make the final diagnosis. What is happening is that, because of the person's experience, the interval between when I see somebody and when I make a definitive diagnosis can differ; sometimes it can look like seconds, and other times, I need to go through multiple processes.

Can multiple diagnoses of a health condition at different health facilities help in determining the accuracy of the health condition?

On a general note, you don't need to do multiple diagnoses or multiple tests to be sure of the diagnosis. The responsibility of doing a test resides with the person asking you to do the test, which is your clinician. Your clinician interprets a test and decides if what they have represents what they expect or has a reason to believe that the test has been properly conducted, and therefore the clinician will go with the results of the test.

Sometimes, patients do have their own ideas. We know that sometimes patients shop for tests, particularly if they are expecting a particular type of result, but that is the patient's problem. We don't expect people to be ordering tests for themselves, but we don't have control over that. If you say someone has sickle cell and they are not aware that maybe their parents have it, there is always a tendency to say something was wrong with the test. If the patient is initiating that move, they are doing it because they have specific concerns and are looking for a different response, but it is not necessary most of the time. If there are benefits in doubt about a diagnosis, it is the prerogative of your clinician to take that judgment. There are certain types of tests that you need some degree of competence to perform; it's not just every test that you put something in the machine; there are some tests that involve your superior. A patient should not, as a matter of fact, order a test and go from laboratory to laboratory to repeat the same test to validate a test.

Sometimes, the people who have conducted a test may not be able to give all the sides of the diagnosis because the diagnosis is not just limited to that test.

How can we reduce and prevent the incidence of misdiagnosis?

Don't go to the wrong people. If you go to the right people, they will walk you through the system. The right person is that person who can see you, acknowledge the situation with you, and can determine whether they know what the problem is. If the person doesn't know, they refer you to the next appropriate level of personnel who can establish the diagnosis. Nothing is wrong if you are being guided through the system along such a track. This is the basis of medical referral in the health system.

We also need to understand that even in the best places, some conditions' diagnoses are not straightforward because of the nature of the condition and what is required to make that diagnosis. There are also conditions that we don't quickly and routinely have the capacity to produce.

Earlier, I said fever can be due to malaria and caused by bacteria or a virus.

In almost all cases, the diagnosis of a viral infection is a bit complicated, but many times, most viral infections are self-limiting. So, we need to be conscious of going through that algorithm that I have said for us to do what is always expected.

So, some conditions have very simple tests that are accessible everywhere. If someone comes with a fever, we can check the blood, but we cannot say if it is malaria or not. If that test turns out to be negative, then you know it is not malaria, so you ask yourself what else it could be. Then there are other types of tests at that point that are indicated; you might need to do a blood culture, if there are bacteria in the blood, the culture will identify them, but that might take a few days before the result comes out.

How does quackery contribute to misdiagnosis in the country?

It is the mother of misdiagnosis because quackery implies that you are not properly trained for what you are trying to do. We need an increasing system of enforcement to ensure that we do not allow quackery in the medical space.

I should, however, underscore the fact that some people may not have started off as appropriately trained personnel like the proprietary patient vendors, but the government has gone a step further, that even for those, there are efforts to engage them and to give them basic training so that the service they are trying to render at that level can be channelled positively.

So, it may not be everybody that we can drive away, but we can engage and demand that anybody who is participating should engage in the right practises for their level. We must understand that there are levels of service delivery.

At the community level, our orientation is to ensure that the members of the community or health worker who might be a trained volunteer are able to carry out some basic characterisation of any patient and able to recognise a patient at risk of dying or whose condition will need something beyond what they can provide at that community level.

If a patient is misdiagnosed, what are the processes involved in reporting the case to the right authority and what are the sanctions involved?

Misdiagnosis is not an offence, primarily. It will only be an offence if you are not supposed to be there.

Even if you go to court, what the court wants to establish is whether you have acted adequately according to your level of competence within the given context at that point in time. However, we need to address quackery. We need to streamline what a health professional can do. If you are a laboratory specialist, then you operate within your laboratory as an individual within the system that you are employed; if you are a pharmacist, you also have your space and some basic treatments to be offered for simple ailments.

Community pharmacists can make diagnoses of some basic things like fever and diarrhoea if they have been trained. They may be able to recognise those conditions and offer an intervention, but they are not the right place for diagnosis for more complex medical problems.

Over-the-counter drugs presume that people will be able to buy some medications for simple things. A clinician should also learn to work with other health workers to get the best of everybody for the benefit of the patient.

To everybody, stay in your lane, do what you are supposed to do, and do what you are trained to do. Everybody is important, and everybody is offering unique services, but the problem arises when we don't stay in our lane.