By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“There are three constants in life: change, choice and principles.” –Steven Covey

Steven Covey notes that actions and intent flow from principles; they are the foundation used to choose between different courses of action and to decide where to invest energy in self-improvement. The importance of principles extends to specific fields as well, including medicine.

In Part I of this series, we reviewed the extent of diagnostic inaccuracy in medicine, ranging from an error rate of 5% to 50%, depending on the nature of the patient/problem. A key contributor to this inaccuracy is our way of thinking about uncertainty: we are trained to be overconfident in the accuracy of our decisions.

Unfortunately, the other extreme, excessive concern about diagnostic uncertainty, leads less confident clinicians to order excessive laboratory and radiological tests. The Choosing Wisely campaign begins to shine a light on the scenarios where such tests are unequivocally useless but does not provide a framework for unnecessary testing when there is even slight uncertainty.

Last year, the American College of Physicians convened a group of experienced clinicians, teachers, and communications experts to address this challenge of diagnostic uncertainty. The product of this effort is called, “Ten Principles for More Conservative, Care-full Diagnosis.” Here is a brief summary of the first five principles:

1. Promoting Enhanced Care and Listening. Perform an appropriate and thoughtful history and physical exam. When the diagnosis is unclear, continue collecting the history and evaluating changes in the physical exam at subsequent visits to determine how the patient’s clinical course is unfolding.
2. Understand Uncertainty. Become comfortable with it, learn how to respond to it, and how to convey it to patients.
3. Respond Carefully to Symptoms. Balance the natural history of common symptoms (75% – 80% of self, resolve within 4 to 12 weeks) with a consideration of potential psychological causes of symptoms (2/3 of patients with anxiety, depression, or somatoform disorders are undiagnosed), considering both the Social Influencers of Health and the long-term effects of Adverse Childhood Events, which also cause or accentuate symptoms.
4. Maximize Continuity and Trust. Continuity of care by a primary care clinician is not only the single best predictor of patient satisfaction but also generates the trust needed to address the psychosocial issues mentioned above and to have patients trust the strategy of “watchful waiting” to observe the natural history of symptoms.
5. Taming the Time Pressures around Patient Visits. Ensure the clinician has adequate time to listen, observe, discuss, and think. Adjust the system and the environment of care, as needed, to support this.

The derivation of these principles, which perhaps seems self-evident, required thought and effort of experts; trying to improve without guiding principles to guide us is disjointed at best. Like moral philosophy, it is the application of principles which is more challenging. Some approaches include taking time to think about how to apply these principles, finding small self-improvements or system changes to move towards achieving them, and telling stories to help reinforce how we approach gaps.

You, as clinical leaders in your settings, have an especially important role to play in helping your clinicians learn and apply these principles. On behalf of your patients, thanks for addressing these challenges in your setting.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

In 2001, the Institute of Medicine (IOM) published Crossing the Quality Chasm, which defined 6 realms of quality:

• Safe
• Effective
• Patient Centered
• Timely
• Efficient
• Equitable

Most quality improvement and quality assurance activities related to health care address one or more of these realms.  However there is one critical area that is missing from both the IOM realms and most QI plans.  This missing realm is at the heart of what it means to be a clinician, is infrequently measured and is uncomfortable to verbalize.

This realm is Accuracy, in particular the diagnostic accuracy of clinicians.

Diagnostic Inaccuracy:  Studies show that between 5 and 50% of diagnoses are erroneous, depending on the type of patient/problem.  The low range applies to a population of patients where most are normal; the high range applies to a population where all patients have complex abnormalities.  Autopsy studies and studies with “secret shopper” patients show rates of inaccuracy of between 10 to 20%.  (Mark Graber:  “The Incidence of Diagnostic Error in Medicine”, BMJ October 2013)

What is the source of this diagnostic inaccuracy?

At the core is an insufficient appreciation of uncertainty.  Put another way, clinicians and scientists are often overconfident in the accuracy of their decisions.  This psychological trait develops when we are trainees, as it makes us appear confident in the eyes of our patients, and helps prevent us from being paralyzed by indecision.  Fortunately, many medical conditions in primary care resolve on their own, so neither the clinician nor the patient ever become aware of the inaccuracy.

We can reduce diagnostic inaccuracy by changing the way that we think.

Daniel Kahneman (winner of the 2002 Nobel Prize in Economics) describes two ways of thinking:

1. Fast thinking (also known as intuitive thinking or system I thinking)
2. Slow thinking (also known as rational thinking or system II thinking)

Fast, intuitive thinking tends to be automatic, with input from emotions.  In his book, Thinking Fast and Slow, Dr. Kahneman notes 12 different classes of bias and 5 heuristics which can lead to irrational decisions, when we think intuitively.

Slow, rational thinking is more deliberative, systematic, and logical, with an evaluation of consequences of a decision.

As we go through our everyday lives and routine practice of medicine, we use fast thinking for most decisions, so we can get through our days without being paralyzed by indecision over minor decisions.  When the stakes are high, or when we notice a diagnostic pattern that doesn’t quite fit, we need to transition to slow, rational thinking.  For a clinician to be efficient and accurate, we need to know when to toggle back and forth between slow and fast thinking.

When slow thinking is associated with a retrospective analysis of a serious diagnostic error, as happens in morbidity and mortality rounds, or when a clinician becomes aware of a diagnostic error that occurred, it is good to explicitly think about which biases or heuristics contributed to the error, to help prompt us to move to slow thinking when needed.

This process is sometimes called “cognitive debiasing,” which is a fancy way of saying “learning from our mistakes”.