New paradigms for better diagnosis
| Traditional ways of thinking about diagnosis, and diagnostic error | New paradigms/better ways to think about diagnosis, and diagnosis improvement |
|---|---|
| General concepts | |
| Good diagnosticians get it right 1st time, most all of the time | Diagnosis is an inexact science, fraught with uncertainty. Goal is to lower error rates and delays via more reliable systems and follow-up |
| Lore, academic model of the master/skilful diagnostician who knows/recalls everything | Quality diagnosis is based on well coordinated distributed network/team of people and reliable processes. Relying less on human memory |
| Diagnosis is the doctor's job | Co-production of diagnosis between clinicians (including nurses, social workers, specialists), lab/radiology, and especially, the patient and family |
| Patients often seen as anxious, exaggerating, overly questioning, with at times unreasonable demands and expectations | Patients as key allies in making diagnosis. Need to address understandable/legitimate fears, desires for explanations. Use their questions to stimulate rethinking of diagnoses. |
| Diagnosis and treatment as separate stages in patient care | Prioritising diagnostic efforts to target treatable conditions; more integrated strategies and timing for testing and treatment |
| Clinical practices | |
| Order lots of tests to avoid missing diagnoses | Judicious ordering: targeted, well organised data and testing. Appreciation of test limitations (false±, incidental findings, risks) |
| More specialty referrals on one hand, but utilisation barriers (co-pays, prior authorisation) on the other. | Pull systems to lower barriers for raising questions, real-time virtual consults; collaborative approaches to enable watch and wait strategies where appropriate |
| Frequent empirical drug trials when uncertain of diagnosis | Conservative use of drugs to avoid confusing clinical picture |
| MD attention/efforts to ensure disease screening | Automating, delegating clerical functions; teamwork, to free MD cognitive time. |
| Thinking about diagnosis errors and challenges | |
| Errors classified as either system or cognitive | Most errors/delays rooted in processes and system design/failures. Errors multifactorial with interwoven, interacting and inseparable cognitive—system factors |
| Errors infrequent; hit-and-miss hearing about errors | Systematically and proactively surveilling of high-risk situations and diagnoses’ performance and outcomes |
| Clinicians reactions: denial, defensive, others to blame, others also making similar errors | Culture of actively and non-defensively seeking to uncover, dig deep to learn from and share errors |
| Dreading complex diagnostic dilemmas | Welcoming intellectual/professional challenges; getting support (time, help) for more complex patients |
| Diagnoses as distinct labels, events | Diagnosis as often fuzzy, multifactorial, evolving over time |
| Documentation/communication | |
| Documentation: time-consuming/wasting, mindless, mainly to CYA (covering your back) | Documentation as useful tool, friend, CYA=canvass for assessment to reflect and share assessments, unanswered questions |
| Say and write as little as possible as it could be used against you in malpractice allegation | Share uncertainties to maximise communication and engagement with other care givers, patients |
| Eschew/hide uncertainty | Leverage, disclose, learn from uncertainty |
| Don't let patient know about errors so they don't become angry, mistrustful, or sue | Patients have right to honest disclosure; often find out about errors anyway (cancer evolves); anticipate, engage concerns |
| Patients advised to call if not better; no news is good news (test results: ‘we'll call if anything abnormal’) | Systematic proactive feedback and follow-up. Calling/emailing to check how patient is doing; survey patient outcomes |
| Global remedies | |
| Knowing more medical knowledge | Knowing the patient (including psychosocial, environmental contexts) |
| Attention to the ‘facts’ to objectively make diagnosis | Acknowledgement of ubiquitous cognitive biases; efforts to anticipate, recognise, counteract, via various de-biasing strategies |
| Exhortations to have ‘high index of suspicion’ of various diagnoses | Less reliance on memory, recall of lectures/reading. Affordances, alerts engineered into work flow; delineation of ‘don't miss’ diagnoses with design of context-relevant reminders |
| Ensuring MD is cc'd everything, thorough/voluminous notes, widespread reminders/alerts | Appreciation of detrimental consequences of information and alert overload; strategies to minimise |
| Redundancies, double checks | Recognition that highly reliable systems are safer than multiple halfway systems |
| Fear of malpractice to motivate MDs to be more careful and practice defensive medicine | Drive out fear, making it safe, joyful to learn from, share errors. Situational awareness of where pitfalls lurk |
| More accountability, ‘P4P’ payment incentives and punishments tied to performance metrics | Clinician engagement in improvement based on trust, collaboration Metric modesty as many best practices yet to be defined/proven |
| More rules, requirements; target outliers for better compliance | Standardisation with flexibility; learning from deviations |
| More time with patients | Better time spent with patients: offloading distractions, more efficient history collection/organisation, longitudinal continuity, and where needed, additional time to talk/think during, before, after visits |
| Reflex changes in response to errors | Avoiding tampering; understanding/diagnosing difference between special versus common cause variation |