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Saturday, May 4, 2013

Diagnosis: why checklists wont do the (whole) job

Perusing the National Patient Safety Foundation website this morning, I noticed a page for patients entitled "Checklist for Getting the Right Diagnosis."  If only it were so simple.

It shouldn't be surprising that a group like NPSF would focus on a "systems" approach to the problem of diagnostic error.  After all, a key learning of the patient safety movement has been that healthcare errors in general can best be understood not as the individual failure of a doctor or nurse, say prescribing or giving a wrong medication, but as malfunctions of our hyper-complex healthcare delivery system susceptible to improvement with more reliable processes, communication protocols and standardization.

So when leaders are confronted with the widespread problem of diagnostic error, it is tempting to fit this issue into the very same framework, and to start thinking about systems-based approaches to a fix.  Hence, the checklist for correct diagnoses.  Therein, patients are advised to be good and accurate historians of their ailment, to keep track of their own test results and, most significantly, to "ask the physician, as a matter of routine, 'could this be anything else?'"  (Presumably this mental jog is intended to influence the physician to think more broadly about the patient's problem, and consider alternate diagnoses.) Here's the problem.

Physicians frequently weigh several diagnoses based on the patient's history and physical examination, narrowing the possibilities as they go on.  This is not a cut-and-dried affair, however.  Common conditions, as a med school aphorism goes, occur commonly.  Uncommon explanations are generally reserved for situations where it is so important not to delay the rarer diagnosis that it is acceptable to consider it seriously until "ruled out" with further investigation.  A common complaint may also point to an uncommon diagnosis when the clues just aren't "adding up" to any of the garden variety explanations - as when the pain is too severe, the duration or tempo of the symptoms is wrong, or a physical finding (like an enlarged lymph node or a peculiar rash) just doesn't make sense in the context of the "usual suspects."

This kind of thinking is dynamic and, one hopes, improves with the experience of the practitioner.  Doctors in training have trouble separating what's relevant from what's not, and so develop long lists of possible diagnoses, even for common complaints, where their supervising physician will quickly hone in on one or two.  As one might imagine, the process is potentially error-prone, which is what makes diagnosis the hardest part of medical practice.

I remember a day some three decades ago in the Pediatric ER at the New York Presbyterian Medical Center.  I was the senior resident, supervising an intern on a chilly January day.  He was presenting a perplexing case - fever, headache, and multiple organ system involvement - coughing, nasal congestion, joint and muscle pain, nausea and lack of appetite.  And yet, the patient's physical examination, beyond a clear nasal discharge, was "within normal limits."  He was clearly baffled. After he reviewed a series of arcane tests and investigations aimed at getting to the bottom of this,  I posed the question..."so why don't you think this is the flu?" 

On the other hand, physicians can go on mental autopilot and fail to recognize when the need exists to think outside the box.  Here's the challenge though - how to be sensitive to the rare bird without taking too many patients on chases of the wild goose, which cause their own problems.  Beyond the matter of cost, the diagnostic Sherlock Holmes will surely cause much unnecessary anxiety and mental anguish, and, from time to time, cause physical harm by aiming a machine gun of tests and treatments at problems when a fly swatter would suffice.

So here's my version of the one-size-fits-all diagnostic checklist.  One: did I remember to listen to the patient?  Two:  have I thought through the problem to the best of my ability?  Three: have I communicated my thoughts clearly to the patient and family?  And finally:  have I checked my hubris at the door?  Because being a good physician means never getting too infatuated with our own ideas and always being open to changing course if doing so is in the best interest of our patient.

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