Table 2.

Clinicians’ identified top ten problems leading to delayed diagnosis in primary care^a

Rank	Problems leading to delayed diagnosis in primary care	Total priority score	Type of factor leading to diagnostic error	Breakdown points in the diagnostic process
1	Poor communication between secondary and primary care; e.g. investigations that are ordered by secondary care are not visible in primary care	78.2	System factor	Referral & consultation
=1	Inverse care law i.e. those who most need medical care are least likely to receive it. Conversely, those with least need of health care tend to use health services more and more effectively	78.2	System and patient-related factor	Access & presentation
3	Patients attending other services such as A&E walk-in centres instead of seeing their own GP	76.6	System and patient-related factor	Access & presentation
4	Multiple symptoms or co-morbidities masking the real problem	76.3	Cognitive factor	Patient-practitioner encounter
5	Lack of continuity of care - seeing different GPs’ for the same problem and never being able to follow ‘a case’ through properly	76.3	System factor	Patient-practitioner encounter
6	Time constraints such as the 10 min consultations that lead to incomplete history-taking and patient examination	76.3	System factor	Patient-practitioner encounter
7	Lack of patient awareness of ‘red flag’ symptoms	76	Patient-related factor	Access & presentation
8	Patient’s delay in presenting symptoms (e.g. “I have had blood in my urine for a year”)	75.4	Patient-related factor	Access & presentation
9	Psychiatric co-morbidity (the co-occurrence of two or more psychiatric diagnoses) leading doctors to insufficient attention to physical symptoms	74.5	Cognitive factor	Patient-practitioner encounter
10	Language and cultural barriers between the GP and the patient	73	System and patient-related factor	Patient-practitioner encounter

(Clinicians scored problems using the following criteria: frequency, severity, inequity, economic impact and responsiveness to solution (Table 1). The scoring options were 1 for “yes (e.g. this problem is common)”, 0 for “no (e.g. this problem is uncommon)”, 0.5 for “unsure (e.g. I am unsure if this problem is common)” and blank for “unaware e.g. I do not know if his problem is common)”. Total Priority score is the mean of the scores for each of the five criteria and is ranging from 0 to 100. Higher ranked problems received more “Yes” responses for each of the criteria and a higher score)

^aAll tables use clinicians’ verbatim statements which were only exceptionally reworded for clarity