Why misdiagnoses are rampant in Nigeria

When an error in diagnosis leads to incorrect treatment, delayed treatment, or no treatment at all, a patient’s condition can be made worse. OYEYEMI GBENGA-MUSTAPHA reports on factors responsible for misdiagnosis across the country and the ways out.

Septuagenarian Mrs. Salome Omotemevo Omatseye was ever fit and vibrant. As a devoted member of God’s Kingdom Society (GKS), she was very active in the church, playing various roles. As a notable chorister, her lively spirit stood her out, especially in major church events, including the Feast of Terbanacles, which holds every December.

One outstanding quality stood her out the more. She never toyed with her health, especially as a senior citizen. And each time she took ill, she would quickly dash to Ahmadiyya Hospital, a privately owned faith based facility in her neighbourhood.

She, however, fell sick last August and was admitted at the hospital. She could neither eat nor drink. Her son, Sam Omatseye, who chairs the Editorial Board of The Nation,  requested a comprehensive test to be run on her. When it was clear that the hospital could not get the root cause of her condition, he requested her referral to Lagos State University Teaching Hospital (LASUTH), Ikeja.

“At LASUTH, the hospital attended to her in her car because there was no room to admit her into. In fact, the hospital could not properly attend to her. There and then, I decided to take her to Lagoon Hospital, Ikeja, where after a week, about N1.5m had been spent, with the hospital still unable to find out what was wrong with her,” Omatseye said.

After much tests, he  said the hospital mentioned something like cancer and wanted to carry out further tests to know its extent. “At that point in time, they kept her in the hospital and showed interest in money rather than life. We kept paying and the hospital could not come out with a definite answer. Scans were being run and we were told they were still investigating. They kept asking for more money rather than work on what was wrong with her in speed of time,” he said.

When it was obvious that his mother’s health was deteriorating, Omatseye directed that the old woman be taken to the Lagos University Teaching Hospital (LUTH), Idi-Araba, where within two days on admission, she was properly diagnosed of cancer of the liver, which had reached the last stage.

Omatseye felt his mother had been misdiagnosed at previous facilities “where she was treated for thyphoid and pains in the legs. None of them discovered a malignant growth in her body until it got too late”.  Madam Omatseye lost the battle on September 14.

Omatseye, smarting from the loss of his dear mother, concluded that some of the doctors are not supposed to be called doctors, adding: “They are not qualified, and what do you expect? There is an educational system where people get grades for money. How do you expect these doctors to know what they are doing? They do not have the patience, or the thoroughness. Most of them are disinterested in what they are doing. They just want money,” he said, adding that the only way out of the mess misdiagnosis has caused is when Nigerians get to the level of suing doctors and hospitals.

“That was how the late Dora Akunyili and the late Gani Fawehinmi were misdiagnosed. How long are we going to continue with this?” he asked.

Like the late Madam Omatseye, many Nigerians have lost their lives to misdiagnosis as nobody is immune from it. Many high profile Nigerians have lost their lives to misdiagnosis, while the lowly and the helpless are dying daily.

What is misdiagnosis? 

According to the Institute of Public Analysts of Nigeria’s (IPAN’s) first Vice President, Dr Femi Oyediran, a misdiagnosis case may involve a wrong diagnosis, a missed diagnosis, a delayed diagnosis, or a failure to recognise complications that change or aggravate an existing condition.

Immediate past President of Association of Medical Laboratory Scientists of Nigeria (AMLSN) and Deputy-Director, Laboratory Services at Nigerian Institute of Medical Research (NIMR),Yaba, Lagos, Dr Toyosi Y. Raheem, said medical misdiagnosis occurs when a medical doctor or any other health care professional fails to diagnose or wrongly diagnoses an illness, disease or health challenge of a patient seeking health care services.

To Dr Raheem, medical misdiagnosis is a serious challenge because it may lead to inappropriate, incorrect or delayed treatment. “It may also cause further damage, prolonged hospital stay, unnecessary financial burden and may cause death. This will also lead to relative poor rating of Nigerian healthcare services when compared to other countries of the world,” he said.

Causes

Possible causes of misdiagnoses, according to Dr Raheem, include excessive workload for healthcare provider (increased workload) as it could put pressure on healthcare provider and consequently lead to misdiagnosis.

Poor or inadequate diagnostic equipment in clinics, medical laboratories, radiology and other departments in hospitals are others identified causes by Dr Raheem. He added: “There are instances where diagnostic equipment such as blood pressure checking device in the clinics, microscopes in the laboratories, X-ray machine in radiology departments etc, are so bad, yet the equipment are being managed due to lack of quality ones. Certainly, such substandard equipment will give misleading results.”

In the same vein, poor budgetary allocation to health services, especially to diagnostic services, also affects outcome of diagnosis. To Dr Raheem, this has reduced most or all health care institutions at primary, secondary and tertiary levels to mere consulting clinics with poor or no diagnostic equipment and accessories.

“An inadequately trained man-power is not a factor that can be swept under the carpet. The quality of training giving to healthcare professionals at the various training institutions is regrettably decreasing, leading to production of inadequately trained physicians, nurses, medical laboratory scientists and other health professionals involved in medical diagnoses.

“Non-conducive work environment is also responsible for misdiagnosis. Erratic power supply, use of wrong healthcare providers to perform specialised diagnostic services, inter-professional hatred or disharmony etc are drivers of misdiagnoses,” he added.

The use of sub-standard or fake diagnostic reagent and equipment by various health care professionals can promote misdiagnoses, according to Dr Raheem.

“Fake or substandard medical diagnostic devices/equipment and their accessories find their ways into Nigerian market through the porous Nigerian borders. Inadequate regulatory activities of health regulatory bodies e.g. Medical and Dental Council of Nigeria, Medical Laboratory Science Council of Nigeria, Nursing and Midwifery Council of Nigeria etc.

“These health regulatory bodies statutorily regulate the activities, equipment and work environments of the respective health professionals. When the regulatory activities of the health regulatory bodies are absent, inadequate or frustrated, medical misdiagnoses will increase and sanctions on offenders will be slowed down or impossible,” Dr Raheem revealed.

Chairman, Medical Advisory Committee (CMAC), LUTH, Dr Femi Fasanmade is of the opinion that medical misdiagnosis comes up when the perception of an attending medic or healthcare giver is wrong, and the patient gets treated for what is not. “For instance, if the physician does not recognise the signs and symptoms properly, or depends on laboratory reports, which are not standardised. Or he interprets them wrongly because he could not decipher what the normal is, from aberrations. Errors could also happen when a patient is labeled wrongly. And wrong results are pushed out. For instance, in x-tray or blood sample taking, if the personnel taking samples are not trained or lack the skill to do what he is doing, there will be room for errors,” Dr Fasanmade said.

He continued: “But if a doctor is very vigilant with sharp acumen, uses standardised laboratories, and watches out for his patients, definitely errors will be picked or reversed, or reduced to the barest minimum. Doctors are human, and human are prone to errors, hence the saying- ‘We care, but God heals’.

“We always encourage health workers to be attentive when at work. This is because if a right breast is cancerous. And the patient is sent to a laboratory for biopsy, and unfortunately a left breast is examined, there is no way a good or confirmatory result will emanate from that test. Also, if a cancerous tissue is supposed to be taken, and the personnel taking it is not skilled, as he pokes the instruments inside the patient, he may take the tissue from non  cancerous part of the body. And if sent to the lab, the patient would be said to have no cancer. That way, the cancer advances, and later if the patient is redone, could be confirmed to have cancer.”

Fasanmade advised that to minimise cases of misdiagnoses, medics and health personnel should always order for appropriate testing, a second opinion, and even third.

“If a result comes out negative against your clinical diagnosis or observations, try a second or even a third opinion. Run another laboratory test. For a life threatening condition, do not depend on just an opinion, either it comes out negative or positive. There is nothing wrong in asking your colleagues, or senior medics to assist you in solving some of these developments. If in a private facility, nothing stops from referring a patient to a teaching hospital, because at tertiary health care, it is a team work. When a member misses out, or an error is committed, another vigilant member of the team will surely pick same up,” he explained.

To a Psychiatrist and Forensic Medical Examiner, Dr Olusola Olowookere, misdiagnosis boils down to medical negligence. A patient, he said, has the right to ask for his medical records. “In the UK, it is a normal thing to do that. All the notes will be compiled and scrutinised to determine at what point a case of negligence was committed. Has this hospital given me the best care they could have done? Every doctor should have that at the back of his mind. It is good to also pray. It is good to also ask if one has done the best for a patient, a candid answer to that question will always put one’s mind at rest. Nobody knows it all, do not be proud, one can always share notes with colleagues, or specialists to get their views without divulging the names of the patient.

“And when you are burnt out, do tell your colleagues to stand in for you. Do not attend to a patient when you are fagged out. In the UK, there is an European working directive that stipulates that nobody can work consecutively for some numbers of hours. You need a clear mind because life is involved and if lost, it cannot be replaced. Prolonged tedious hours of work exert the brain and impacts on concentration level, and output,”Dr Olowookere said.

He believed the rise in cases of misdiagnosis is partly because best brains are leaving the country in droves to America and Europe. According to him, a friend, who just graduated, said everybody in that class/set is already enrolled for PLAB examination or USMUE, “if they all passed at an attempt or two or third attempt that means they will all leave the country. What is the government doing about that? Remuneration is a whole kettle of fish here. The basic things needed to be provided by the government to ensure minimal cases of misdiagnoses, for instance, ambulance to pick patients at home or scene of medical crises. While in the ambulance, a doctor can perform basic things to stabilise a patient, and prognosis for diagnosis and treatment are much better.”

Dr Olowookere said there should be an interaction between a doctor and his patients. “Every patient should be made to know what he is being treated for, the drugs being given, and possible outcomes. Here in Nigeria, a patient is expected to be passive, which is an abnormality elsewhere. There are situation where a patient will even proffer a solution to the problem, possibly from past experiences in the family,” he said.

Solutions

According to the experts, part of the solutions include: workload assessment of healthcare providers involved in diagnosis needs to be determined by governments at all levels. Where workload is excessive, more appropriate healthcare professionals should be employed.

Budgetary allocations to diagnostic services such as the clinics, medical laboratories and radiology etc., should be improved upon to ensure provision of adequate and modern diagnostic reagent, equipment and other needed accessories.

There should be curriculum review in all training institutions such as universities, colleges of health sciences etc., to enhance production of high quality human resources for health in Nigeria.

Work environment should be conducive. Power supply in health institutions should be improved upon. Inter-professional, interdisciplinary collaborations should be improved upon in the interest of the patients. This will lead to effective referral system and drastically reduce or eliminate cases of medical misdiagnosis.

All health regulatory bodies should be strengthened to perform their statutory duties. Any erring health care professionals or quacks or health institutions should be decisively dealt with according to the enabling laws regulating the respective medical professions.