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A survey of outpatient Internal Medicine clinician perceptions of diagnostic error

  • John C. Matulis EMAIL logo , Susan N. Kok , Eugene C. Dankbar and Andrew J. Majka
From the journal Diagnosis



Little is known about how practicing Internal Medicine (IM) clinicians perceive diagnostic error, and whether perceptions are in agreement with the published literature.


A 16-question survey was administered across two IM practices: one a referral practice providing care for patients traveling for a second opinion and the other a traditional community-based primary care practice. Our aim was to identify individual- and system-level factors contributing to diagnostic error (primary outcome) and conditions at greatest risk of diagnostic error (secondary outcome).


Sixty-five of 125 clinicians surveyed (51%) responded. The most commonly perceived individual factors contributing to diagnostic error included atypical patient presentations (83%), failure to consider other diagnoses (63%) and inadequate follow-up of test results (53%). The most commonly cited system-level factors included cognitive burden created by the volume of data in the electronic health record (EHR) (68%), lack of time to think (64%) and systems that do not support collaboration (40%). Conditions felt to be at greatest risk of diagnostic error included cancer (46%), pulmonary embolism (43%) and infection (37%).


Inadequate clinician time and sub-optimal patient and test follow-up are perceived by IM clinicians to be persistent contributors to diagnostic error. Clinician perceptions of conditions at greatest risk of diagnostic error may differ from the published literature.

Corresponding author: John C. Matulis, III DO, MPH, Division of Community Internal Medicine, Mayo Clinic, 200 1st St. SW., Rochester, MN 55905, USA, Phone: +507-284-5278


Many thanks to Ann Harris, Wendy Daniels and Sarah Jenkins from the Mayo Clinic Survey Research Center for their assistance in preparation and execution of this survey and in review of relevant components of the manuscript.

  1. Author contributions: John C. Matulis: Dr. Matulis is a Consultant and Assistant Professor in Medicine at Mayo Clinic in Rochester, MN. He was involved in the conceptualization, planning and design of the project, and in the development and execution of the survey. He drafted the initial manuscript, reviewed and revised the manuscript and approved the final manuscript as submitted. Susan Kok: Dr. Kok is a Senior Associate Consultant and an Assistant Professor of Medicine at Mayo Clinic in Rochester, MN. She was involved in the conceptualization, planning and design of the project and assisted in the iterative development and execution of the survey. Dr. Kok performed the statistical analysis on the data collected and assisted in drafting and revising the manuscript. She reviewed and revised all sections of the manuscript, and approved the final manuscript as submitted. Eugene Dankbar: Mr. Dankbar is a Senior Health Systems engineer and an Assistant Professor of Health Care System Engineering at Mayo Clinic in Rochester, MN. He assisted in the conceptualization and planning of the project and provided feedback on the survey development process. He assisted in the development of the manuscript, contributed to revisions and approved of the final manuscript as submitted. Andrew Majka: Dr. Majka is a Consultant and an Assistant Professor of Medicine at Mayo Clinic in Rochester, Minnesota. He was involved in the conceptualization, planning and design of the project and the development and execution of the survey. He assisted in the development of the manuscript, contributed to revisions and approved the final manuscript as submitted. All the authors have accepted responsibility for the entire content of this submitted manuscript and approved of this submission.

  2. Research funding: The administration of this survey was funded in part through an anonymous grant through the Mayo Clinic Department of Development.

  3. Employment or leadership: None declared.

  4. Honorarium: None declared.

  5. Competing interests: The funding organization played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication

  6. Financial disclosure: None declared.

  7. Conflicts of interest: None declared.


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Supplementary Material

The online version of this article offers supplementary material (

Received: 2019-10-02
Accepted: 2019-12-05
Published Online: 2020-01-09
Published in Print: 2020-05-26

©2020 Walter de Gruyter GmbH, Berlin/Boston

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