Understanding Diagnostic Overshadowing

Have you ever heard a patient complain about a symptom(s), only to be dismissed by the provider or another member of the interdisciplinary team? The patient’s report of symptoms is overlooked without a thorough assessment, bloodwork, or diagnostic imaging. Many of us have either witnessed this or personally experienced it. It turns out this phenomenon has a name, ‘diagnostic overshadowing (DO).’

This phenomenon occurs when a healthcare provider attributes a patient’s symptoms to an already established diagnosis, rather than investigating other potential co-morbid conditions or underlying causes. In essence, the initial diagnosis "overshadows" the opportunity to identify other, potentially new or co-existing conditions.  In this article, we’ll explore how and why diagnostic overshadowing occurs, who it impacts most, and how healthcare professionals, especially travelers, can actively prevent it.

Why is this an issue? 

The lack of taking the patient’s symptoms seriously leads to a failure to properly assess, diagnose, or treat additional health issues that might be affecting the patient. Have you ever provided care to a patient who was discharged from the hospital, then re-admitted to the ED? 

Here’s an example: A patient with a history of substance abuse who presents with chest pain might have their symptoms dismissed as being drug-related without further investigation. The healthcare provider might overlook other critical factors, like a cardiac event or another underlying health condition.

Here’s another example:

A patient with a history of anxiety presents with shortness of breath and tachycardia. Healthcare professionals, including travelers, might jump to the conclusion that the patient is likely having an anxiety or panic attack, rather than looking into other causes such as respiratory distress, sepsis, or conditions that decrease cardiac output (e.g., hemorrhage, dehydration, shock, or heart failure).

Diagnostic overshadowing and sentinel events

Diagnostic overshadowing can directly contribute to sentinel events by leading to delayed or missed diagnoses that result in serious harm or death. Sentinel events are unexpected occurrences involving death or serious physical or psychological injury. The Joint Commission (TJC) issued a Sentinel Event Alert regarding diagnostic overshadowing, highlighting the risk it poses to patient safety, particularly for individuals with intellectual and developmental disabilities. 

Diagnostic overshadowing is a form of cognitive bias where healthcare professionals assume symptoms are related to a pre-existing condition (like an intellectual or developmental disability) rather than exploring other potential medical causes. This delay in turn, can lead to missed diagnoses, inappropriate or inadequate treatment, and increased risk of adverse events. 

Who is at highest risk for diagnostic overshadowing?

Diagnostic overshadowing disproportionately impacts certain vulnerable groups who experience health disparities. 

These groups experience three common themes:

1. They often face systemic biases

2. They have lower access to healthcare

3. They have complex health care needs that aren’t always fully understood 

Groups at risk include:

1. Individuals with a history of substance abuse

2. LGBTQ+ patients, who may face biases related to gender or sexual orientation

3. Patients with low health literacy, who might struggle to communicate symptoms effectively

4. Obese individuals, whose health issues are often dismissed as "weight-related"

5. People with disabilities, especially those with neurodeficits or cognitive impairments

6. People with mental health conditions, where psychiatric symptoms might overshadow physical health concerns.

Why missing the full picture can hurt patients

Diagnostic overshadowing is a serious concern because it can lead to:

• Missed or Delayed Diagnosis: When interdisciplinary team members attribute new symptoms to an existing condition without proper evaluation, patients may not receive a timely diagnosis, which can worsen their condition or cause delays with treatment.

• Increased Risk for Sentinel Events: The Joint Commission has recognized diagnostic overshadowing as a contributor to sentinel events, which are unanticipated situations that result in significant harm to a patient. 

The role of cognitive bias

At the heart of diagnostic overshadowing lies cognitive bias. Cognitive bias refers to the unconscious tendency of healthcare professionals to make judgments based on pre-existing knowledge or stereotypes. 

I’m sure many of you have witnessed this. Have you ever heard your colleague say, ‘He’s just looking for pain meds because he’s an addict’? Here comes the uncomfortable self-reflection part. Have you ever practiced care with a generalization or stereotype?  ⁠ When we operate with, we run the risk of overlooking key elements that impede our ability to provide high-quality, safe patient care. This can lead to suboptimal care, medical errors, and delayed interventions. unconscious or conscious cognitive bias

Case study: Diagnostic Overshadowing in Action

Larissa has a history of depression and anxiety. She came into the ED presenting with chest pain and difficulty breathing. Jack, RN, was the triage nurse at Yikes Hospital. He saw Larissa’s past medical history of anxiety, and his initial assumption was that the symptoms were anxiety-related. He provided the Charge Nurse and ED physician with the SBAR, which included his assessment. This caused a delay in prioritizing the care for this patient. When Larissa was waiting to be seen by the provider, Sueli, the Respiratory Therapist, passed by and noticed that Larissa was dyspneic. When the team arrived at the bedside, they did a stat EKG and bloodwork.  Results of the EKG showed an ST-elevation MI (STEMI). *A STEMI occurs when there is a complete blockage of a coronary artery, leading to the death of heart muscle (myocardial infarction). This damage to the heart muscle causes the release of various proteins, one of which is troponin. Larissa’s troponins were significantly elevated / positive. The delay in recognizing this condition led to significant complications and a longer recovery time. ⁠This case study is a stark reminder of how easily a pre-existing condition can overshadow a new, life-threatening problem.

5 ways travel clinicians can make a difference

As clinicians who travel, you are in a unique position to impact patient care on a broad scale. Now that you are starting to understand what this could look like, let’s go over five simple ways you can actively help reduce the occurrence of diagnostic overshadowing and improve patient outcomes.

1. Be aware of diagnostic overshadowing

Now that you understand what diagnostic overshadowing is, you are much more likely to recognize when it might happen. Being aware of potential biases, whether related to a patient’s substance abuse history, obesity, disability, or mental health, is crucial.

2. Use effective listening and interviewing skills

Engage patients in conversation that allows them to express their symptoms and history in detail. Active listening and empathetic interviewing techniques can foster stronger patient-provider relationships and give you a more comprehensive understanding of the patient's health beyond the obvious diagnosis. Asking inquisitive questions in order to understand the full situation is another key skill. For example, ‘Thank you for sharing that with me. I'm really sorry you're going through this. To better understand the full picture and support your care, I’d like to ask you a few more questions. You mentioned that you aren’t taking the Lisinopril anymore. Do you recall when you last took your Lisinopril, and was there something specific that made you stop?’

3. Speak up and escalate concerns

If you believe a patient’s symptoms are being overlooked due to their pre-existing condition, it’s important to speak up. Escalate concerns using the appropriate chain of command. This might include the manager/supervisor, charge, or department head. The Nomad Health team can provide support and guidance to frame your concern in a professional and meaningful way. Advocating for patients ensures that their symptoms are addressed properly, leading to better outcomes.

4. Review the organization’s ADA compliance

Take the time to familiarize yourself with your organization’s compliance with the Americans with Disabilities Act (ADA). Become familiar with the policies and procedures that are in place to address the specific needs of patients with disabilities, particularly those with cognitive or neurological impairments. 

5. Foster shared decision-making

Shared decision-making is essential in building trust with patients. Ensure they feel heard and respected in their care process. Patients have the right to understand the risks, benefits, and alternatives to make sound decisions about their care. As patient advocates, we have to continually do our part to ensure patients' rights are respected.

Commitment to seeing the whole patient

As clinicians, we have an ethical responsibility to ensure that all patients receive comprehensive, unbiased care. Diagnostic overshadowing is a frequently unrecognized yet serious issue that can significantly impact the quality of care, especially for vulnerable populations. By remaining vigilant, communicating effectively, advocating for our patients, and critically examining our own assumptions, we can help prevent misdiagnosis and ensure all patients receive the attention and treatment they deserve.

What we permit, we ultimately promote. That’s why it’s essential to commit to looking beyond assumptions and truly listening to our patients. Together, we can each contribute towards a culture where all symptoms are thoroughly considered, and diagnoses are timely, accurate, and grounded in respect, ultimately helping to prevent diagnostic overshadowing.