ISQUA17-3085BALANCING DIAGNOSTIC ERRORS WITH CONSERVATIVE DIAGNOSIS: DEVELOPING A NEW PARADIGM FOR MORE APPROPRIATE DIAGNOSIS

Abstract

Objectives: The US National Academy of Medicine report has focused worldwide attention and opened unprecedented opportunities to address diagnostic errors and delays. However, there is a need for a more dialectical view and understanding of diagnosis, one that incorporates the problem of over-diagnosis-going beyond merely balancing trade-offs between diagnosis errors and delays (under-diagnosis) and over-diagnosis and wasteful over-testing. This more nuanced view must treat these related problems as two sides of the same coin, with the unifying concept being better and more appropriate diagnosis. Some diagnoses are being made and treated well beyond their effect on patients' health and well-being, with diagnostic interventions causing harm that outweigh any benefits, yet other diagnoses that would help relieve suffering are being missed entirely. To address this long-standing problem, we aim to develop a series of principles conservative diagnosis principles and practices Methods: Principles were developed modeled off of previouslypublished Principles of Conservative Prescribing. A series of focused brainstorming meetings were held to collect expert opinion and formulate concepts for more conservative, careful, appropriate diagnosis. Primary care and specialty physicians were convened and feedback was gathered at several national conferences including the Lown Institute Road to Right Care, the Society to Improve Diagnosis in Medicine Conference, and Diagnostic Error in Medicine-After the IOM Report: What's Next Conferences. Results: Broad practice and policy categories were developed that serve as the foundation for Principles of Conservative Diagnosis and include 1) need to develop a new model for patient “caring” that avoids equating more testing with taking patients' concerns seriously; 2) creating new science of clinical uncertainty; 3) rethinking common symptoms, especially nonspecific symptoms seen in primary care; 4) (re)prioritizing diagnoses based on treatment imperatives and effectiveness; 5) taming time to facilitate more time with patients and watchful waiting; 6) better appreciating test limitations; 7) leveraging continuity relationships; 8) incorporating diagnostic safety lessons and anticipating “don't miss diagnoses” and pitfalls; 9) new approaches to timely cancer diagnosis; 10) transforming the role of specialists and EDs from current status of promoters of non-conservative diagnosis; 11) prospective guidelines for approaching common problems; and 12) understanding, overcoming barriers, fragmentation, lack of coordination as key drivers of suboptimal diagnosis. Conclusion: Striking a balance between missed/delayed diagnosis with overdiagnosis and over-testing represents a linear view. A more dialectical approach must focus on more appropriate diagnostics rather than just fewer tests (rather than “less is more,” “more is less!”). This new approach should be based on general principles, not just lists of tests to avoid. These general principles incorporate fundamentals of a good diagnosis (careful exam, listening to the patient, avoiding known biases, understanding limitations of diagnostic tests) with the critical approaches based on the precautionary principle, primary care principles, key patient safety lessons, and a healthy scepticism of market-oriented medicine. Key principles must enhance the patient's role in co-producing a diagnosis, appreciate/ minimize patient and provider anxieties, as well as identify when early definitive diagnosis represents the best and most conservative strategy.