Ten Principles for More Conservative, Care-Full DiagnosisFREE

We were pleased to read Dr. Schiff and colleagues’ the “Ten Principles of a More Conservative Care-Full Diagnosis” and encourage medical providers to adopt this approach widely (1). We feel the principles are particularly applicable to trauma informed care.

Adverse childhood experiences (ACEs) and adult trauma are prevalent but often not acknowledged within the medical context. Patients who have experienced traumatic events often feel a loss of control over their bodies, their relationships, and their lives. Their traumatic experiences, including ACEs and adult trauma, may manifest as physical symptoms as well as increased health care use and costs (2). This association is consistent with our experience working with an urban Medicaid population with a high prevalence of ACEs and adult trauma. As the authors note, at least a third of common symptoms that prompt medical visits will not have a clear-cut medical diagnosis (3). Somatization after trauma is not fully understood, but negative affectivity and feelings of incompetence are associated with somatoform symptoms (4). Furthermore, pain is often exacerbated by the patient’s anxiety and distress, leading to further disability.
Patients and providers alike often have little understanding of the link between trauma and physical symptoms and may continue to seek an explanation and treatment for the problem. In many cases, patients may undergo considerable medical testing without any abnormal findings or with incidental findings, which in some cases can be “hypothesis generating” (5) and lead to unnecessary diagnostics and intervention. Unfortunately, negative findings on diagnostic testing have not been found to be reassuring for most patients (5). As Dr. Schiff and colleagues note, our profession often fails to consider the harm that may arise from testing (1).

Using an approach such as the one outlined in “Ten Principles” allows a traumatized patient to participate in medical decision-making, which can empower the patient and promote healing. Continuity of care is also a critical component of building a relationship with a traumatized patient by creating trust, allowing the patient to feel safe, and building on knowledge of the individual’s patterns and coping abilities.
The public health burden of untreated trauma is enormous and costs the health care system billions of dollars in unnecessary medical tests and procedures. Many of those dollars would be better spent on integrating behavioral health services into primary care and acknowledging the deep connection between physical symptoms and trauma.

References

1. Schiff GD, Martin SA, Eidelman DH, Volk LA, Ruan E, Cassel C, et al. Ten Principles for More Conservative, Care-Full Diagnosis. Ann Intern Med [Internet]. 2018 Oct 2 [cited 2018 Oct 24]; Available from: http://annals.org/article.aspx?doi=10.7326/M18-1468
2. Katon W. Medical Symptoms without Identified Pathology: Relationship to Psychiatric Disorders, Childhood and Adult Trauma, and Personality Traits. Ann Intern Med. 2001 May 1;134(9_Part_2):917.
3. Kroenke K. A Practical and Evidence-Based Approach to Common Symptoms: A Narrative Review. Ann Intern Med. 2014 Oct 21;161(8):579.
4. Elklit A, Christiansen DM. Predictive factors for somatization in a trauma sample. Clin Pract Epidemiol Ment Health. 2009 Jan 6;5(1):1.
5. Page LA, Wessely S. Medically Unexplained Symptoms: Exacerbating Factors in the Doctor-Patient Encounter. J R Soc Med. 2003;96:223–7.

The article published by Schiff and colleagues in the category “Ideas and Views” deals with a crucial subject (1). As the authors point out, diagnostic errors are frequent and constitute a major public health and quality of care issue. Recently, Makay & Daniel pointed out that medical error -the most frequent of which is diagnostic error- is the third leading cause of death in the United States (2). The article by Schiff and colleagues provides many avenues for reflection that deserve to be taken into consideration by physicians and that require additional research.

Schiff and colleagues write in particular that “Time is a powerful incubator for diagnosis” and that “Having adequate time to listen, observe, discuss, and reflect is a decisive factor that separates good diagnosis from under- and overdiagnosis” (1). We believe that this statement should be considered with caution. The notion that taking more time allows for a better diagnosis is part of the “debiaising” strategies (3). The authors’ advice on the importance of “Being aware of potential diagnostic error” is part of the same strategies. Debiaising strategies have recently been criticized in a literature review (4). In particular, several studies have shown that taking more time to diagnose does not increase diagnostic performance and may even reduce it (5,6). Other studies have shown opposite or contradictory results, with differences depending on the degree of complexity of the case and the clinicians’ level of experience. They have been criticized for the protocol used, which has sometimes been developed to generate biases resulting from the way the case was initially presented to subjects or the way in which subjects were trained (6). In their review, Norman et al. concluded that “strategies focused on the reorganization of knowledge to reduce errors” are the only ones with “small but consistent benefits” (4).

It therefore seems important to us not to consider that debiaising strategies, several of which are described in the article by Schiff and colleagues, will systematically be associated with an improvement in the quality of the diagnostic process and performance. In addition to the recommendations by Schiff and colleagues, it should be stressed that training has an important role to play in improving diagnostic performance, as it determines how students’ knowledge will organize in long-term memory. It could also be a determining factor in transforming the physician’s relationship to uncertainty, as part of the development of a “New science of uncertainty”, as suggested by the authors (1). The challenge is to reduce physicians’ intolerance to uncertainty, an important factor in overprescribing diagnostic tests.

1. Schiff GD, Martin SA, Eidelman DH, Volk LA, Ruan E, Cassel C, et al. Ten Principles for More Conservative, Care-Full Diagnosis. Ann Intern Med. 2018 Nov 6;169(9):643-646.
2. Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016 May;353:i2139.
3. Croskerry P. When I say… cognitive debiasing. Med Educ. 2015 Jul;49(7):656–7.
4. Norman GR, Monteiro SD, Sherbino J, Ilgen JS, Schmidt HG, Mamede S. The Causes of errors in clinical reasoning: Cognitive biases, knowledge deficits, and dual process thinking. Acad Med. 2017 Jan;92(1):23–30.
5. Ilgen JS, Bowen JL, McIntyre LA, Banh KV, Barnes D, Coates WC, et al. Comparing diagnostic performance and the utility of clinical vignette-based assessment under testing conditions designed to encourage either automatic or analytic thought. Acad Med. 2013 Oct;88(10):1545–51.
6. Sherbino J, Dore KL, Wood TJ, Young ME, Gaissmaier W, Kreuger S, et al. The relationship between response time and diagnostic accuracy. Acad Med. 2012 Jun;87(6):785–91.

"Ten Principles for More Conservative, Care-Full Diagnosis" is much more than a perspective piece. As intended, its authors incorporate not just principles of decreasing diagnostic harm but highlight the dearth of time to accomplish what matters to patients and caregivers; the need for clinical reasoning to precede diagnostic testing; and the central roles of continuity, humility, and trust in the doctor-patient relationship. I offer that the article should be considered a landmark publication, to be actively taught and broadly reflected upon within undergraduate and graduate medical education.

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 Medicine
Bruce Lambert - Center for Communication and Health, Northwestern University
Lisa Sanders – Yale Medical School
Aziz Sheikh Usher Institute of Population Health, University of Edinburgh




1. 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, Lowe B. The challenge of diagnosing non-specific, functional, and somatoform disorders: A systematic review of barriers to diagnosis in primary care. J Psychosom Res. 2016;80:1-10. Epub 2016/01/02. doi: 10.1016/j.jpsychores.2015.11.002. PubMed PMID: 26721541.
3. Kroenke K. A practical and evidence-based approach to common symptoms: a narrative review. Ann Intern Med. 2014;161(8):579-86. Epub 2014/10/21. doi: 10.7326/M14-0461. PubMed PMID: 25329205.
4. Sherbino J, Dore KL, Wood TJ, Young ME, Gaissmaier W, Kreuger S, et al. The relationship between response time and diagnostic accuracy. Acad Med. 2012;87(6):785-91. Epub 2012/04/27. doi: 10.1097/ACM.0b013e318253acbd. PubMed PMID: 22534592.