Balancing the challenges of underdiagnosis (missing or delaying important diagnoses) and overdiagnosis (labeling patients with diseases that may never cause suffering or death) can feel like walking across a canyon on a tightrope. Diagnostic errors occur in an estimated 10 percent to 20 percent of cases and will affect most Americans at least once in their lifetime. They are the leading cause of medical malpractice claims, harming more than 4 million people at a cost of more than $100 billion.
Developing effective means to prevent diagnostic error has become an urgent priority. Physicians may compensate by ordering expensive, and often unnecessary, tests, scans, lab work and specialist referrals. However, those extra tests may not yield any better or more specific explanations, and could cause harm to the patient through false positives, delayed treatment, permanent disability or death.
So how can physicians find the “sweet spot” between doing too much, or too little? That was the question posed by Gordon Schiff, M.D., associate director of Brigham and Women’s Center for Patient Safety Research and Practice at a workshop during this week’s Society to Improve Diagnosis in Medicine (SIDM) conference in New Orleans.
There has been increasing national attention on overdiagnosis, overtesting, and overtreatment, he said, referring to this Wall Street Journal article. In reality, it’s two sides of the same coin, Schiff told the audience of physicians, nurses, administrators and policymakers. “What we’re striving for in all cases is the appropriate, conservative diagnosis. One that is smarter, safer, thoughtful, rational and honest.”
To get there, Schiff says doctors should keep some core principles at the forefront of every diagnostic decision. These concepts go beyond just doing fewer tests; it’s doing more appropriate testing, collaboration and providing better care.
A 2015 report from the Institute of Medicine concluded that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. The authors called for urgent change to address the situation and to improve health care quality and safety.
The committee defines diagnostic error as “the failure to establish an accurate and timely explanation of the patient’s health problem(s) or communicate that explanation to the patient.” It often results from multiple causes: inadequate collaboration and communication among clinicians, patients and families; a system poorly designed to support the diagnostic process; and a culture that discourages transparency and disclosure of diagnostic errors.
What is a good diagnosis? According to Schiff, an associate professor of medicine at Harvard Medical School, and quality and safety director for the Harvard Medical School Center for Primary Care, it begins with the fundamentals — a need for a differential diagnosis, listening to the patient and obtaining a good history, conducting a careful exam, matching the syndrome to the findings; understanding the limitations of diagnostic tests; avoiding known biases, premature closure and hindsight; and using Bayesian probability weighing, a means to calculate conditional probabilities.
He combines these fundamentals with four paradigms: precautionary restraint, which shifts the burden of proof for new technology; primary care principles of teamwork, which include continuity of care and continuing relationships; key patient safety lessons such as situational awareness, safety nets and a culture of safety; and a critique of market medicine’s mindset — employing a healthy skepticism to counter biases favoring overuse, and thinking about the situation longer-term.
It’s a lot to remember and synthesize. So Schiff and his colleagues developed a set of 10 core principles based on this framework:
- Promoting a new model for caring
- Developing a new science of uncertainty
- Rethinking symptoms
- Maximizing continuity and trust
- Taming time
- Linking diagnosis to treatment
- Tests: more thoughtful ordering and interpreting
- Safety nets: incorporating lessons from diagnosis errors
- Addressing cancer: fears and challenges
- Transforming specialists and ED physicians into conservative diagnosis stewards
“We need to shift this construct of what it means to really be caring about the patient. It’s not about ordering a lot of tests for patients,” said Schiff. “We need to really hear what the patients’ concerns are and address them and try to help them.” It also means partnering, communicating with and educating patients to help them understand that medicine is an inexact science. There are limitations of modern medicine and testing, but we will work together to find out what’s really going on, he said.
A conservative diagnosis doesn’t mean saying no to all tests; it means being more judicious in choosing which tests are appropriate for the situation and when. This helps to avoid potential harm, whether that’s complications from invasive tests or downstream harm from false positives or from overtreatment caused by overdiagnosis, or false reassurance stemming from false negatives. While conservative diagnoses also seek to minimize unnecessary referrals to specialists, Schiff said that primary physicians can leverage additional expertise by encouraging specialists to play a stewardship role. For example, they could act as a safety net through triage consults, electronic second opinions and counsel patients whose diagnosis may have been initially delayed.
A conservative diagnosis, first and foremost, is a way of respecting patients and doctors’ own limits, Schiff concluded. “It’s not fundamentally about saying no to people; you can’t actually ignore their legitimate fears or uncertainty. It’s actually about saying yes, enabling, helping and supporting them, creating safety nets, creating a new science of collaboration around that certainty.”
Rather than less is more, it’s really more is less. More support for the patient, more watching, more listening, more focused testing, and taking more time to think things through.