New rules for diagnosis

Experts propose diagnostic competencies and principles.

Internists have been diagnosing patients for centuries, but two presentations at the Diagnostic Error in Medicine 11th International Conference, held in November 2018 in New Orleans, offered new approaches to the diagnostic process.

Despite medical education's shift toward competency-based assessment of trainees, diagnosis is largely taught the same way it always was, said Andrew P. Olson, MD, FACP. “The way that I learned to diagnose acute kidney injury was the way my teacher learned to diagnose it, which is the way that their teacher learned to diagnose it,” he said. “And I'm pretty sure stuff has changed since the '50s.”

Many of the Core Entrustable Professional Activities for Entering Residency that medical students must demonstrate are related to diagnosis, noted Dr. Olson, an assistant professor of medicine at the University of Minnesota Medical School in Minneapolis. However, competency is still typically assessed through an “I know it when I see it” approach, he said.

Dr. Olson and other clinician educators are working to update the system for measuring diagnostic competency. A group of experts from various medical education organizations, including ACP, the Association of American Medical Colleges, and the Accreditation Council for Graduate Medical Education, recently met in Minneapolis to rate the importance and feasibility of 85 potential competencies.

New competency expectations

Photo courtesy of Dr Olson
Photo courtesy of Dr. Olson

During his talk, Dr. Olson reviewed the top 12 competencies chosen by the group to improve diagnosis through a new consensus curriculum. “I think they're really valuable and, for the first time, describe what we need to attain in our health professions education programs,” he said. The first six competencies focus on the individual clinician, the next three focus on teams, and the final three are related to the system.

The competencies for individuals are 1) Accurately and efficiently collect key clinical findings needed to inform diagnostic hypotheses, 2) Formulate or contribute to an accurate representation of the problem, 3) Produce or contribute to a prioritized differential diagnosis, 4) Justify the prioritization by comparing and contrasting the patient's findings to characteristic disease presentations, 5) Use decision support tools, such as checklists and second opinions, to improve accuracy, and 6) Use critical thinking and reflection to improve performance.

“The individual must recognize, perhaps most importantly, that we're fallible—that human cognition is imperfect, prone to error, and we need to guard against that,” Dr. Olson said. “If we could begin to say we are fallible humans doing our best, I think we're better off than expecting perfection.”

For health care teams, which include patients, families, and caregivers, the competencies are 1) Engage and collaborate with patients and families in accord with their values and preferences, and educate patients about the diagnostic process, 2) Collaborate with other health care professionals and communicate effectively throughout the diagnostic process, and 3) Apply effective strategies at transitions of care, and close the loop on communication of test results.

Finally, competencies related to the system of care include 1) Discuss how human factors contribute to diagnostic safety and error, and take steps to mitigate common flaws in the health care system, 2) Advance a culture of safety that encourages open dialogue and learning from feedback, and 3) Disclose diagnostic errors and near misses transparently to patients, team members, and risk management staff.

Now the Society to Improve Diagnosis in Medicine is putting these competencies to the test, with the implementation of new curricula at four pilot medical schools and their partner health professional schools, funded by a three-year grant from the Josiah Macy Jr. Foundation.

Going beyond ‘less is more’

Even for physicians who have finished training, the rules of diagnosis are changing. Experts often portray diagnosis as a pendulum that, when swung too far in either direction, becomes overdiagnosis or underdiagnosis. But ACP Member Gordon D. Schiff, MD, said this is the wrong way to look at it.

“Overdiagnosis and underdiagnosis are two sides of the same coin,” he argued. “It's not like we need to trade off one for another or too much of one is too little of the other.”

This is why, to reach more appropriate diagnoses, clinicians need general principles that go beyond lists of tests to avoid, said Dr. Schiff, a practicing general internist and an associate professor of medicine at Harvard Medical School in Boston. “We need to do the right thing for the right reasons. . . . It has to be about not just fewer tests, but more appropriate testing and better care.”

In a recent article, published in November 2018 by Annals of Internal Medicine, Dr. Schiff and coauthors summarized 10 general principles for conservative diagnosis. The list, an expert consensus based on panel discussions and deliberations, was developed by combining fundamentals of good diagnosis with four key paradigms: the precautionary principle, tenets of primary care, patient safety lessons, and critique of “market medicine,” he said.

Dr. Schiff, who is also associate director at the Brigham and Women's Center for Patient Safety Research and Practice and quality safety director for the Harvard Medical School Center for Primary Care in Boston, detailed the principles during his talk at the conference. Copresenter Sumit Agarwal, MD, ACP Resident/Fellow Member, a primary care physician and research fellow at the Brigham and Women's Hospital in Boston, spoke about the lessons that can be learned from medical errors.

Promoting a new model for enhanced caring and listening. Compared to physicians who dismiss nonspecific symptoms, those who order imaging tests, antibiotics, and subspecialty referrals are perceived by patients as caring, Dr. Schiff noted. “We need to get beyond that as a construct,” he said. “We need to really hear what the patient's concerns are and address them and try to help them and work with them, engaging the patient's role in co-producing the diagnosis.”

Developing a new science of uncertainty. “It's a word we weren't using much in medicine until recent years,” said Dr. Schiff, emphasizing the need to recognize how often diagnoses and differential diagnoses are wrong. “We need to appreciate the apprehension that leads to, and we really need to re-engineer care and how we communicate with patients.”

The best way to do this remains unclear. For example, after Dr. Schiff's group developed a leaflet for patients to explain that medicine is an inexact science, patient focus groups had critical feedback. “[One group] said patients don't really care about uncertainty,” he said. “We said, ‘Don't you want us to be honest when we don't know?’ They said, ‘Well, patients don't want to be made more anxious.’ That kind of sent us back to the drawing board.”

To help patients better understand diagnostic uncertainty, Dr. Schiff recommended that physicians acknowledge the impact of symptoms, be transparent about uncertainty, and create a concrete plan. He recommended against assuming patients' wishes (“Just ask!” he stressed), overwhelming them with a list of possibilities, diminishing symptoms, or referring to subspecialists or testing without explaining why.

Rethinking symptoms. “It turns out, a lot of these symptoms in primary care, we can't get an answer,” said Dr. Schiff. “We have to rethink how we approach common symptoms. Diagnostic strategies emphasizing organic causes may be inadequate.”

Maximizing continuity and trust. Longitudinal primary care relationships are the foundation for building better, more conservative diagnosis, he said. “Patients need to feel like I'm not making a decision to save the insurance company money. We need financial neutrality in these decision makings.”

Taming and taking time. Physicians are not taught how to engineer proactive watchful waiting, “which really shouldn't mean neglecting,” said Dr. Schiff. “Explain why the test of time is a useful test.” However, there has to be enough time in the first place. “If I only have six minutes to see a patient, I'm not going to be able to do this. It's just easier to order the test,” he said.

Linking diagnosis to treatment. “We should think about what the connection is between the possible treatments and the diagnostic testing considerations, especially in low-risk, nonurgent situations,” Dr. Schiff said.

Ordering and interpreting tests more thoughtfully. “Tests distract us from the more important work of talking to people,” and awareness of the potential harms of diagnostic testing is important, he said. Examples include direct harm from invasive studies, incidental findings, anxiety from diagnosis, and stigmatizing labels.

“The risks of these adverse effects may be more or less frequent depending on the test, the patient, or the clinical context,” said Dr. Schiff. “But they need to be recognized, weighed, and minimized to the greatest extent possible when ordering and performing diagnostic tests, and this isn't really being done.”

Building safety nets. “That's not safety-net hospitals or safety-net clinics; it's building safety nets within the diagnostic process using what we know about diagnostic errors,” said Dr. Agarwal. One example of a diagnostic safety net is red flags for don't-miss diagnoses, he said.

Dr. Agarwal has also looked at diagnostic pitfalls, defined as clinical patterns or vulnerabilities that lead to diagnostic error. His research group came up with 600 disease-specific pitfalls in 20 general categories. One of the most common pitfalls was that disease A was repeatedly misdiagnosed as disease B (e.g., colorectal cancer was misdiagnosed as another gastrointestinal disease), and another was the failure to appreciate limitations of a test result.

“If we address these, if we think about them, it frees us up to practice more conservatively,” said Dr. Agarwal. “In order to do this, we have to be able to harness the diagnostic errors we do know about.”

Addressing cancer: fears and challenges. Cancer is a disease everybody fears, as well as a leading cause of outpatient malpractice, and physicians need to help patients see the bigger picture, said Dr. Schiff. “We're just going to have to be able to figure out a way of talking about cancer. . . . Every diagnosis of cancer is delayed, in a sense. We don't get that first abnormal cell division,” he said.

Transforming the role of subspecialists and ED physicians into diagnostic stewards. “Specialists are not the problem,” Dr. Schiff said. “We need to get them as part of the solution, help them give us guidelines about being conservative and not overtesting, and be able to give us reassurances and ways of reassuring our patients.”

In sum, adapting a more conservative approach to diagnosis is not fundamentally about saying no to people with a “less is more” philosophy, Dr. Schiff said. “It's really ‘more is less': More support for the patient, more careful watching, more hearing from the patient, more understanding of the test, more focused testing, more worry-free lives—fewer diagnostic errors,” he said.