Table 1

New paradigms for better diagnosis

Traditional ways of thinking about diagnosis, and diagnostic errorNew paradigms/better ways to think about diagnosis, and diagnosis improvement
General concepts
 Good diagnosticians get it right 1st time, most all of the timeDiagnosis 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 everythingQuality diagnosis is based on well coordinated distributed network/team of people and reliable processes. Relying less on human memory
 Diagnosis is the doctor's jobCo-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 expectationsPatients 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 carePrioritising diagnostic efforts to target treatable conditions; more integrated strategies and timing for testing and treatment
Clinical practices
 Order lots of tests to avoid missing diagnosesJudicious 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 diagnosisConservative use of drugs to avoid confusing clinical picture
 MD attention/efforts to ensure disease screeningAutomating, delegating clerical functions; teamwork, to free MD cognitive time.
Thinking about diagnosis errors and challenges
 Errors classified as either system or cognitiveMost 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 errorsSystematically and proactively surveilling of high-risk situations and diagnoses’ performance and outcomes
 Clinicians reactions: denial, defensive, others to blame, others also making similar errorsCulture of actively and non-defensively seeking to uncover, dig deep to learn from and share errors
 Dreading complex diagnostic dilemmasWelcoming intellectual/professional challenges; getting support (time, help) for more complex patients
 Diagnoses as distinct labels, eventsDiagnosis as often fuzzy, multifactorial, evolving over time
 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 allegationShare uncertainties to maximise communication and engagement with other care givers, patients
 Eschew/hide uncertaintyLeverage, disclose, learn from uncertainty
 Don't let patient know about errors so they don't become angry, mistrustful, or suePatients 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 knowledgeKnowing the patient (including psychosocial, environmental contexts)
 Attention to the ‘facts’ to objectively make diagnosisAcknowledgement of ubiquitous cognitive biases; efforts to anticipate, recognise, counteract, via various de-biasing strategies
 Exhortations to have ‘high index of suspicion’ of various diagnosesLess 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/alertsAppreciation of detrimental consequences of information and alert overload; strategies to minimise
 Redundancies, double checksRecognition that highly reliable systems are safer than multiple halfway systems
 Fear of malpractice to motivate MDs to be more careful and practice defensive medicineDrive 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 metricsClinician 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 complianceStandardisation with flexibility; learning from deviations
 More time with patientsBetter 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 errorsAvoiding tampering; understanding/diagnosing difference between special versus common cause variation