Ten Principles for More Conservative, Care-Full Diagnosis

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 Listening Patients 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 Uncertainty As 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 Symptoms Up 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 Trust Continuity 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 Time Time 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 Treatment Diagnosis 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 Thoughtfully Conservative 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 Errors Recent 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 Challenges Patients 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 Clinicians Implicit 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. Conclusion Achieving 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).