Ten Principles for More Conservative, Care-Full Diagnosis

Ideas and Opinions6 November 2018Ten Principles for More Conservative, Care-Full DiagnosisFREEGordon D. Schiff, MD, Stephen A. Martin, MD, EdM, David H. Eidelman, MD, Lynn A. Volk, MHS, Elise Ruan, BS, Christine Cassel, MD, William Galanter, MD, Mark Johnson, MD, MS, Annemarie Jutel, PhD, Kurt Kroenke, MD, Bruce L. Lambert, PhD, Joel Lexchin, MSc, MD, Sara Myers, BA, Alexa Miller, MA, Stuart Mushlin, MD, Lisa Sanders, MD, and Aziz Sheikh, MDGordon D. Schiff, MDBrigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (G.D.S., M.J.), Stephen A. Martin, MD, EdMUniversity of Massachusetts Medical School, Worcester, Massachusetts (S.A.M.), David H. Eidelman, MDMcGill University, Montreal, Quebec, Canada (D.H.E.), Lynn A. Volk, MHSBrigham and Women's Hospital, Boston, Massachusetts, and Partners HealthCare, Somerville, Massachusetts (L.A.V., S.M.), Elise Ruan, BSBrigham and Women's Hospital and Tufts University School of Medicine, Boston, Massachusetts, and Partners HealthCare, Somerville, Massachusetts (E.R.), Christine Cassel, MDKaiser Permanente School of Medicine, Pasadena, California (C.C.), William Galanter, MDUniversity of Illinois, Chicago, Chicago, Illinois (W.G.), Mark Johnson, MD, MSBrigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (G.D.S., M.J.), Annemarie Jutel, PhDHarvard Medical School, Boston, Massachusetts; Victoria University of Wellington, Wellington, New Zealand (A.J.), Kurt Kroenke, MDIndiana University, Indianapolis, Indiana (K.K.), Bruce L. Lambert, PhDNorthwestern University, Chicago, Illinois (B.L.L.), Joel Lexchin, MSc, MDYork University, Toronto, Ontario, Canada (J.L.), Sara Myers, BABrigham and Women's Hospital, Boston, Massachusetts, and Partners HealthCare, Somerville, Massachusetts (L.A.V., S.M.), Alexa Miller, MAArtsPractica, Guilford, Connecticut (A.M.), Stuart Mushlin, MDBrigham Circle Medical Associates, Boston, Massachusetts (S.M.), Lisa Sanders, MDYale University School of Medicine, New Haven, Connecticut (L.S.), and Aziz Sheikh, MDThe University of Edinburgh, Edinburgh, United Kingdom (A.S.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M18-1468 Annals Author Insight Video - Gordon D. Schiff, MD In this video, Gordon D. Schiff, MD, offers additional insight into the article, "Ten Principles for More Conservative, Careful Diagnosis." SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Many spotlights currently illuminate the challenges associated with medical diagnosis. The National Academy of Medicine estimates that all patients will experience 1 serious diagnostic error during their lifetime, and diagnostic errors are now the leading cause of medical malpractice claims (1, 2). To avoid missing diagnoses, clinicians often order imaging and/or laboratory studies and initiate specialist referrals. However, physicians and patients are also urged to use fewer tests; nearly every U.S. medical specialty and 20 countries worldwide have initiated Choosing Wisely campaigns (3). Evidence increasingly shows that indiscriminate diagnostic testing and referrals often fail to provide definitive explanations or improve outcomes and at times are more harmful than beneficial.Balancing underdiagnosis (missing or delaying important diagnoses) and wasteful, harmful overdiagnosis (labeling patients with diseases that may never cause suffering or death) is often portrayed as the need "to keep the pendulum from swinging too far in either direction" (4). Rather than framing the problem as a simple, linear tradeoff, we believe it must be more fundamentally conceptualized as 2 sides of the same coin unified by the need for more cautious and careful approaches.We assembled a diverse group of clinicians, educators, and health policy and communication experts to create recommendations to support improved approaches to clinical care and health policy (www.patientsafetyresearch.org/Schiff_Ten_Principles_Conservative_Diagnosis.pdf). Building on our previous conservative principles of medication prescribing (5), we developed 10 overarching principles based on core attributes of care (good communication, trusting relationships, and continuity of care) and key patient safety lessons (awareness of pitfalls, safety nets to mitigate harm, and a culture that facilitates learning/avoiding blame) that go beyond current test-by-test recommendations.Promoting Enhanced Caring and ListeningPatients come to clinicians seeking explanations for their symptoms. Clinicians often rely on laboratory and imaging studies and specialist referrals to rule out serious diagnoses and identify patients who could benefit from particular treatments. However, this approach rests on the questionable assumptions that testing is key to making an accurate diagnosis, an exact diagnosis is always available and needed to select therapies, and ordering tests best shows that clinicians are taking patients' concerns seriously.Medicine currently shortchanges the patient history and physical examination, even though carefully listening to and observing patients over time often provide more valuable information than multiple radiologic or chemical tests. We must stop equating testing with caring and thoroughness and instead emphasize respectful listening, examination, follow-up, and collaboration with the patient to "coproduce" diagnoses (1, 6).Developing a New Science of UncertaintyAs precision medicine becomes a major preoccupation, appreciation of the pervasiveness of uncertainty in medicine has paradoxically increased (7). We need to develop a new science and praxis of diagnostic uncertainty that acknowledges complex biological and social systems and serves as a starting point for more modest, reflective, and conservative practice. Doing so requires acknowledging widespread uncertainty, better operationalizing follow-up, and communicating honestly about uncertainty.Rethinking SymptomsUp to one half of symptoms defy definitive medical diagnosis. Further, many symptoms are self-limiting: 75% to 80% of symptoms improve over 4 to 12 weeks, usually regardless of medical intervention (8). Some patients meet criteria for depression, anxiety, or somatoform illnesses, yet these diagnoses are overlooked in two thirds of patients. Visits for "medically unexplained symptoms" currently represent the fastest-growing type of medical encounter. Caring for these patients can be frustrating, leading clinicians to be dismissive or stigmatizing. We need to move away from exhaustively trying to rule out multiple rare diseases and then labeling patients' symptoms as nonorganic, toward more helpful and supportive approaches.Maximizing Continuity and TrustContinuity is the foundation of judicious clinical practice. Without knowledgeable, trusting relationships, clinicians must often resort to defensive, inadequately informed, and costly styles of practice. Health systems that maximize relational and informational continuity perform better and cost less (9), and patients value having clinicians who know them well. Financial incentives can undermine long-term, trusting relationships. If clinicians are incentivized to withhold tests, patients may find trusting "watch-and-wait" recommendations difficult (3).Taming and Taking TimeTime is the currency of clinical care. Although few clinicians would disagree in principle with the conservative diagnosis practices that we advocate, many argue that they simply do not have time for prolonged discussions about uncertainty, exploration of symptoms in greater detail, or comprehensive follow-up. Time is a powerful incubator for diagnosis. Conservative diagnosis requires carefully and skillfully weighing information as it evolves. Having adequate time to listen, observe, discuss, and reflect is a decisive factor that separates good diagnosis from under- and overdiagnosis. Practical strategies include redesigning care to optimize the roles of other team members and reengineering electronic health records and follow-up systems to support watchful waiting, a fundamental pillar of conservative diagnosis and an antidote to the unwatchful neglect that patients fear (10).Linking Diagnosis to TreatmentDiagnosis needs to stand less alone and more arm in arm with treatment. The value of diagnosis is greater in conditions with effective, specific, or urgent treatments and more limited if no therapy is available, a diagnosis is not needed to select among treatment options, and/or treatment can be safely deferred. Diagnosing conditions for which patients have no interest in being treated (for example, chemotherapy and surgery) may be unwarranted and disrespectful.Ordering and Interpreting Tests More ThoughtfullyConservative diagnosis is not just saying "no" to tests or the patients requesting them. Rather, it is about more intelligently selecting, timing, sequencing, interpreting, and weighing the marginal benefits of tests. Few appreciate the biases and lack of rigor involved in evaluating new diagnostic tests, which are not subject to the same evidence and regulatory standards as medications. We also often do not fully consider the potential harms of testing (Table).Table. Potential Harms From Diagnostic Testing*Safety Nets: Incorporating Lessons From Diagnostic ErrorsRecent attention given to diagnostic errors might seem to argue for more aggressive defensive medicine to rule out myriad diagnoses lest they be missed and labeled as errors and delays. However, additional testing does not necessarily result in answers that patients and clinicians seek. Being aware of potential diagnostic errors can help avoid pitfalls and build safety nets and systems to protect against known errors.Addressing Cancer: Fears and ChallengesPatients understandably fear missed cases of cancer. Almost any symptom can be due to cancer. Clinicians and the media have long promoted early diagnosis, but serious controversies surround efforts to screen for and diagnose most types of cancer. These issues are complex. Furthermore, data are often inconclusive or conflicting, particularly considering such issues as lead-time bias; overdiagnosis of cancer that is incidentally discovered but best left untreated; false-positive and false-negative test results; uncertainties about the value of treatment; and questions about the marginal benefit of early treatment. We need to help patients understand the toll imposed by false-positive results and overdiagnosed cancer to appreciate the need to strike a balance between treating the few with harmful cancer and avoiding harm to the many without it.Diagnostic Stewardship: Transforming the Role of Specialists and Emergency Department CliniciansImplicit in conservative diagnosis is minimizing indiscriminate use of specialty referrals and emergency departments. However, both specialists and emergency department clinicians can positively contribute by leveraging their knowledge and playing stewardship roles. Specialists can provide guidance when testing or referring is not needed and offer safety nets (such as triage electronic consultations/second opinions and guidelines) to conservatively assess and reassure patients. Emergency department clinicians can work with primary care clinicians to help reduce unnecessary emergency department visits while helping to expedite truly urgent evaluations.ConclusionAchieving more judicious diagnosis mandates policy support to redesign care at both the individual patient and system levels. Practical safety nets can protect the safety and quality of diagnosis and promote more conservative practice (www.patientsafetyresearch.org/Schiff_Ten_Principles_Conservative_Diagnosis.pdf).References1. Balogh E, Miller BT, Ball J, eds. Improving Diagnosis in Health Care. Washington, DC: National Academies Pr; 2015. Google Scholar2. Schiff GD, Puopolo AL, Huben-Kearney A, Yu W, Keohane C, McDonough P, et al. Primary care closed claims experience of Massachusetts malpractice insurers. JAMA Intern Med. 2013;173:2063-8. [PMID: 24081145] doi:10.1001/jamainternmed.2013.11070 CrossrefMedlineGoogle Scholar3. Levinson W, Kallewaard M, Bhatia RS, Wolfson D, Shortt S, Kerr EA; Choosing Wisely International Working Group. "Choosing Wisely": a growing international campaign. BMJ Qual Saf. 2015;24:167-74. [PMID: 25552584] doi:10.1136/bmjqs-2014-003821 CrossrefMedlineGoogle Scholar4. Landro L. A medical detective story: why doctors make diagnostic errors. The Wall Street Journal. 26 September 2015 Accessed at www.wsj.com/articles/a-medical-detective-story-why-doctors-make-diagnostic-errors-1443295859 on 7 September 2018. Google Scholar5. Schiff GD, Galanter WL, Duhig J, Lodolce AE, Koronkowski MJ, Lambert BL. Principles of conservative prescribing. Arch Intern Med. 2011;171:1433-40. [PMID: 21670331] doi:10.1001/archinternmed.2011.256 CrossrefMedlineGoogle Scholar6. Hart JT. Clinical and economic consequences of patients as producers. J Public Health Med. 1995;17:383-6. [PMID: 8639335] MedlineGoogle Scholar7. Simpkin AL, Schwartzstein RM. Tolerating uncertainty—the next medical revolution? N Engl J Med. 2016;375:1713-5. [PMID: 27806221] CrossrefMedlineGoogle Scholar8. Kroenke K. A practical and evidence-based approach to common symptoms: a narrative review. Ann Intern Med. 2014;161:579-86. [PMID: 25329205]. doi:10.7326/M14-0461 LinkGoogle Scholar9. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457-502. [PMID: 16202000] CrossrefMedlineGoogle Scholar10. Schiff GD. Minimizing diagnostic error: the importance of follow-up and feedback. Am J Med. 2008;121:S38-42. [PMID: 18440354] doi:10.1016/j.amjmed.2008.02.004 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Gordon Schiff, Kurt Kroenke, Bruce Lambert, Lisa Sanders, Aziz SheikhHarvard, Indiana University, Northwestern University, Yale, University of Edinburgh5 February 2019 Response We are grateful for these comments highlighting different but important aspects of the relevance of our "Ten Principles for More Conservative, Care-Full Diagnosis" (full version is available at http://www.patientsafetyresearch.org/Schiff_Ten_Principles_Conservative_Diagnosis.pdf).Rediger and Miles describe key intersections between the high prevalence of trauma (childhood, adult), and clinic/office visits for physical symptoms that lack a clear medical diagnosis. We agree and suggest that diagnostic challenges in caring for this important group of patients perfectly illustrate the point we make in our introduction to the 10 principles – that under- and over-diagnosis are not opposite, competing pitfalls to avoid. Instead, they are two sides of the same coin that must be understood and approached holistically rather than trade off one at the expense of the other. Patients, particularly female patients, have experienced centuries of misdiagnosis when they presented with physical symptoms that were dismissed as "psychological," "hypochondriacal," "nonorganic," or even "hysterical"(1). At the same time, patients with serious prior or ongoing trauma are often not diagnosed and referred for the help they need, but instead are subjected to needless imaging, labs, and stigma (when the tests return normal) (2). Overcoming this requires, as we elaborate in the 10 Principles, an approach that emphasizes better listening, continuity, trusting relationships, appreciation of test limitations, and, yes…. time.Pelaccia, however, warns that "more time to diagnose may not be a good idea." He cites findings from case vignettes given to medical trainees. In the real world, there are two types of time: cross-sectional (within a single visit) and longitudinal (across several visits). Within a visit, a careful history is adequate for 75% of the diagnoses for patients presenting with symptoms (3). There is clearly a threshold below which clinicians lack sufficient time to take an adequate history, reflect, discuss with the patient and meaningfully document their thinking. Many clinicians would argue they are bumping up against this lower limit of minimum time. Across visits, follow-up has been found to sort out the majority of symptoms that resolve in 2-12 weeks (3). By "time is an incubator" we meant both types of time and emphasized the importance of "follow-up systems to support watchful waiting." Even Sherbino (who Pelaccia cites) acknowledges that "with routine cases rapid processing is both efficient and effective. However, when cases are more demanding, there may be value in more deliberative thinking" (4).Finally, we thank Meisel for endorsement of our 10 Principles.Gordon Schiff - Brigham and Women's Hospital, Harvard Medical School Center for Primary Care Kurt Kroenke - Regenstrief Institute, Indiana University School of MedicineBruce Lambert - Center for Communication and Health, Northwestern University Lisa Sanders – Yale Medical School Aziz Sheikh Usher Institute of Population Health, University of Edinburgh1. Tasca C, Rapetti M, Carta MG, Fadda B. Women and hysteria in the history of mental health. Clin Pract Epidemiol Ment Health. 2012;8:110-9. Epub 2012/11/02. doi: 10.2174/1745017901208010110. PubMed PMID: 23115576; PubMed Central PMCID: PMCPMC3480686.2. Murray AM, Toussaint A, Althaus A, B. The of and somatoform A of to diagnosis in primary care. J Epub doi: PubMed PMID: Kroenke K. A practical and evidence-based approach to common symptoms: a narrative review. Ann Intern Med. Epub doi: PubMed PMID: Sherbino J, W, S, et al. The between time and diagnostic Med. Epub doi: PubMed PMID: L. 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MA, Medical leading cause of in the 2015 Sherbino J, The of errors in clinical knowledge and thinking. Med. D, et al. diagnostic and the of clinical testing conditions to either or Med. Sherbino J, W, S, et al. The between time and diagnostic Med. The 10 Principles and Care We were to Schiff and the "Ten Principles of a More Conservative Care-Full Diagnosis" and medical to this approach We the principles are particularly to trauma and trauma are but often not the medical who have experienced often a of over their their relationships, and their and may as physical symptoms as as increased health care use and (2). is with our experience with an with a high prevalence of and the at a of common symptoms that medical visits will not have a medical diagnosis (3). trauma is not fully but and of are associated with somatoform symptoms (4). Furthermore, is often by the and leading to and often have of the between trauma and physical symptoms and may to an and treatment for the In many patients may medical testing without any findings or with which in cases can be and to unnecessary and findings on diagnostic testing have not been found to be for most patients Schiff and our often to consider the harm that may from testing an approach such as the one in "Ten a patient to in medical which can the patient and promote Continuity of care is also a of a with a patient by the patient to and on knowledge of the and health of trauma is and the health care system of in unnecessary medical tests and Many of would be better on health into primary care and acknowledging the between physical symptoms and Schiff GD, E, C, et al. Principles for More Conservative, Care-Full Ann Intern 2 Medical without to and and Ann Intern Med. Kroenke K. A Practical and to A Ann Intern Med. 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Article, and Disclosure Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (G.D.S., of Massachusetts Medical School, Worcester, Massachusetts University, Montreal, Quebec, Canada and Women's Hospital, Boston, Massachusetts, and Partners HealthCare, Somerville, Massachusetts (L.A.V., and Women's Hospital and Tufts University School of Medicine, Boston, Massachusetts, and Partners HealthCare, Somerville, Massachusetts Permanente School of Medicine, Pasadena, California of Illinois, Chicago, Chicago, Illinois Medical School, Boston, Massachusetts; Victoria University of Wellington, Wellington, New Zealand University, Indianapolis, Indiana University, Chicago, Illinois University, Toronto, Ontario, Canada Guilford, Connecticut Circle Medical Associates, Boston, Massachusetts University School of Medicine, New Haven, Connecticut University of Edinburgh, Edinburgh, United Kingdom Martin, Eidelman, Cassel, Galanter, Johnson, Jutel, Kroenke, Lambert, Lexchin, Mushlin, Sanders, and Sheikh and are members of an assembled for of conservative diagnosis The no in the or of the or of the or or of the The findings and in this are of the and do not necessarily represent the of the Gordon and The thank for support and for From the Gordon and can be at Gordon D. Schiff, MD, Brigham and Women's Hospital, Boston, Author Brigham and Women's Hospital, Boston, Health University, Montreal, Partners HealthCare, Somerville, Tufts University, 2 Boston, of Medicine, Chicago, Department of Medicine, Hospital, Victoria University of Wellington, New Regenstrief Institute, Indianapolis, Northwestern University, Chicago, University, Toronto, Guilford, Brigham Circle Medical Associates, Boston, Hospital, New Haven, Usher Institute of Population Health and The University of Edinburgh, United and Schiff, Martin, Eidelman, Volk, Ruan, of the Schiff, Martin, Eidelman, Volk, Ruan, Cassel, Galanter, Johnson, A. Jutel, K. Kroenke, Lambert, J. Lexchin, Myers, A. Miller, Mushlin, L. Sanders, A. of the for important Schiff, Martin, Eidelman, Volk, Ruan, Cassel, Galanter, Johnson, A. Jutel, K. Kroenke, Lambert, J. Lexchin, Myers, A. Miller, Mushlin, L. Sanders, A. of the Schiff, Martin, Eidelman, Volk, Ruan, Cassel, Galanter, Johnson, A. Jutel, K. Kroenke, Lambert, J. Lexchin, Myers, A. Miller, Mushlin, L. Sanders, A. of Schiff, or Volk, Ruan, at on 2 2018. Annals Author Insight Video - Gordon D. Schiff, MD In this video, Gordon D. Schiff, MD, offers additional insight into the article, "Ten Principles for More Conservative, Careful Diagnosis." Principles for More Conservative, Care-Full Diagnosis and Miles Principles for More Conservative, Care-Full Diagnosis Pelaccia Principles for More Conservative, Care-Full Diagnosis L. Meisel Principles for More Conservative, Care-Full Diagnosis Gordon D. Schiff Kurt Kroenke Bruce L. 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