Gordon D. Schiff, MD; Stephen A. Martin, MD, EdM; David H. Eidelman, MD; Lynn A. Volk, MHS; Elise Ruan, BS; Christine Cassel, MD; William Galanter, MD; Mark Johnson, MD, MS; Annemarie Jutel, PhD; Kurt Kroenke, MD; Bruce L. Lambert, PhD; Joel Lexchin, MSc, MD; Sara Myers, BA; Alexa Miller, MA; Stuart Mushlin, MD; Lisa Sanders, MD; Aziz Sheikh, MD
Note: Drs. Martin, Eidelman, Cassel, Galanter, Johnson, Jutel, Kroenke, Lambert, Lexchin, Mushlin, Sanders, and Sheikh and Ms. Myers are members of an expert panel assembled for collaborative development of conservative diagnosis principles.
Disclaimer: The funding source had no role in the design or conduct of the study; collection, analysis, or interpretation of the data; or preparation or review of the manuscript. The findings and conclusions in this commentary are those of the authors and do not necessarily represent the official position of the Gordon and Betty Moore Foundation.
Acknowledgment: The authors thank Ami Karlage for editorial support and Andrea Lim for manuscript support.
Grant Support: From the Gordon and Betty Moore Foundation.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-1468.
Corresponding Author: Gordon D. Schiff, MD, Brigham and Women's Hospital, 1620 Tremont Street, 3rd Floor, Room 03-02-2N, Boston, MA 02120; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Schiff: Brigham and Women's Hospital, 1620 Tremont Street, 3rd Floor, Room 03-02-2N, Boston, MA 02120.
Dr. Martin: Barre Family Health Center, 151 Worcester Road, Barre, MA 01005.
Dr. Eidelman: McGill University, 3605 Rue de la Montagne, Montreal, Quebec H3G 2M1, Canada.
Ms. Volk: Partners HealthCare, 399 Revolution Drive, Somerville, MA 02145.
Ms. Ruan: Tufts University, 2 Hawthorne Place, Boston, MA 02114.
Dr. Cassel: 64 Lodge Trail, Santa Fe, NM 87506.
Dr. Galanter: Section of Academic Internal Medicine, 840 S. Wood, 440D, Chicago, IL 60612. Dr. Johnson: Department of Medicine, Mount Auburn Hospital, 330 Mount Auburn Street, Cambridge, MA 02138.
Prof. Jutel: Victoria University of Wellington, PO Box 600, Kelburn, Wellington 6140, New Zealand.
Dr. Kroenke: Regenstrief Institute, 1101 West 10th Street, RF 221, Indianapolis, IN 46202.
Dr. Lambert: Northwestern University, 710 N. Lake Shore Drive, 15th Floor, Chicago, IL 60611.
Dr. Lexchin: York University, 4700 Keele Street, Toronto, Ontario M3J 1P3, Canada.
Ms. Myers: 2783 Lancashire Road, Apartment 10, Cleveland, OH 44106.
Ms. Miller: 201 Dromara Road, Guilford, CT 06437.
Dr. Mushlin: Brigham Circle Medical Associates, 75 Francis Street, Boston, MA 02115.
Dr. Sanders: St. Raphael's Hospital, 1450 Chapel Street, Room M423E, New Haven, CT 06511.
Dr. Sheikh: Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, United Kingdom.
Author Contributions: Conception and design: G.D. Schiff, S.A. Martin, D.H. Eidelman, L.A. Volk, E. Ruan, S. Myers.
Drafting of the article: G.D. Schiff, S.A. Martin, D.H. Eidelman, L.A. Volk, E. Ruan, C. Cassel, W. Galanter, M. Johnson, A. Jutel, K. Kroenke, B.L. Lambert, J. Lexchin, S. Myers, A. Miller, S. Mushlin, L. Sanders, A. Sheikh.
Critical revision of the article for important intellectual content: G.D. Schiff, S.A. Martin, D.H. Eidelman, L.A. Volk, E. Ruan, C. Cassel, W. Galanter, M. Johnson, A. Jutel, K. Kroenke, B.L. Lambert, J. Lexchin, S. Myers, A. Miller, S. Mushlin, L. Sanders, A. Sheikh.
Final approval of the article: G.D. Schiff, S.A. Martin, D.H. Eidelman, L.A. Volk, E. Ruan, C. Cassel, W. Galanter, M. Johnson, A. Jutel, K. Kroenke, B.L. Lambert, J. Lexchin, S. Myers, A. Miller, S. Mushlin, L. Sanders, A. Sheikh.
Obtaining of funding: G.D. Schiff, L.A. Volk.
Administrative, technical, or logistic support: L.A. Volk, E. Ruan, S. Myers.
Table. Potential Harms From Diagnostic Testing*
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In this video, Gordon D. Schiff, MD, offers additional insight into the article, "Ten Principles for More Conservative, Careful Diagnosis."
Katherine Rediger, CRNP, D.R. Bailey Miles, MD
Johns Hopkins Community Physicians
October 25, 2018
The 10 Principles and Trauma Informed Care
We were pleased to read Dr. Schiff and colleagues’ the “Ten Principles of a More Conservative Care-Full Diagnosis” and encourage medical providers to adopt this approach widely (1). We feel the principles are particularly applicable to trauma informed care.Adverse childhood experiences (ACEs) and adult trauma are prevalent but often not acknowledged within the medical context. Patients who have experienced traumatic events often feel a loss of control over their bodies, their relationships, and their lives. Their traumatic experiences, including ACEs and adult trauma, may manifest as physical symptoms as well as increased health care use and costs (2). This association is consistent with our experience working with an urban Medicaid population with a high prevalence of ACEs and adult trauma. As the authors note, at least a third of common symptoms that prompt medical visits will not have a clear-cut medical diagnosis (3). Somatization after trauma is not fully understood, but negative affectivity and feelings of incompetence are associated with somatoform symptoms (4). Furthermore, pain is often exacerbated by the patient’s anxiety and distress, leading to further disability.Patients and providers alike often have little understanding of the link between trauma and physical symptoms and may continue to seek an explanation and treatment for the problem. In many cases, patients may undergo considerable medical testing without any abnormal findings or with incidental findings, which in some cases can be “hypothesis generating” (5) and lead to unnecessary diagnostics and intervention. Unfortunately, negative findings on diagnostic testing have not been found to be reassuring for most patients (5). As Dr. Schiff and colleagues note, our profession often fails to consider the harm that may arise from testing (1). Using an approach such as the one outlined in “Ten Principles” allows a traumatized patient to participate in medical decision-making, which can empower the patient and promote healing. Continuity of care is also a critical component of building a relationship with a traumatized patient by creating trust, allowing the patient to feel safe, and building on knowledge of the individual’s patterns and coping abilities.The public health burden of untreated trauma is enormous and costs the health care system billions of dollars in unnecessary medical tests and procedures. Many of those dollars would be better spent on integrating behavioral health services into primary care and acknowledging the deep connection between physical symptoms and trauma.References1. Schiff GD, Martin SA, Eidelman DH, Volk LA, Ruan E, Cassel C, et al. Ten Principles for More Conservative, Care-Full Diagnosis. Ann Intern Med [Internet]. 2018 Oct 2 [cited 2018 Oct 24]; Available from: http://annals.org/article.aspx?doi=10.7326/M18-14682. Katon W. Medical Symptoms without Identified Pathology: Relationship to Psychiatric Disorders, Childhood and Adult Trauma, and Personality Traits. Ann Intern Med. 2001 May 1;134(9_Part_2):917. 3. Kroenke K. A Practical and Evidence-Based Approach to Common Symptoms: A Narrative Review. Ann Intern Med. 2014 Oct 21;161(8):579. 4. Elklit A, Christiansen DM. Predictive factors for somatization in a trauma sample. Clin Pract Epidemiol Ment Health. 2009 Jan 6;5(1):1. 5. Page LA, Wessely S. Medically Unexplained Symptoms: Exacerbating Factors in the Doctor-Patient Encounter. J R Soc Med. 2003;96:223–7.
Thierry Pelaccia, MD, MEd, PhD
Centre for Training and Research in Health Sciences Education (CFRPS), Faculty of Medicine, University of Strasbourg, France
November 12, 2018
Taking more time to diagnose may not be a good idea... despite its apparent obviousness!
The article published by Schiff and colleagues in the category “Ideas and Views” deals with a crucial subject (1). As the authors point out, diagnostic errors are frequent and constitute a major public health and quality of care issue. Recently, Makay & Daniel pointed out that medical error -the most frequent of which is diagnostic error- is the third leading cause of death in the United States (2). The article by Schiff and colleagues provides many avenues for reflection that deserve to be taken into consideration by physicians and that require additional research.Schiff and colleagues write in particular that “Time is a powerful incubator for diagnosis” and that “Having adequate time to listen, observe, discuss, and reflect is a decisive factor that separates good diagnosis from under- and overdiagnosis” (1). We believe that this statement should be considered with caution. The notion that taking more time allows for a better diagnosis is part of the “debiaising” strategies (3). The authors’ advice on the importance of “Being aware of potential diagnostic error” is part of the same strategies. Debiaising strategies have recently been criticized in a literature review (4). In particular, several studies have shown that taking more time to diagnose does not increase diagnostic performance and may even reduce it (5,6). Other studies have shown opposite or contradictory results, with differences depending on the degree of complexity of the case and the clinicians’ level of experience. They have been criticized for the protocol used, which has sometimes been developed to generate biases resulting from the way the case was initially presented to subjects or the way in which subjects were trained (6). In their review, Norman et al. concluded that “strategies focused on the reorganization of knowledge to reduce errors” are the only ones with “small but consistent benefits” (4).It therefore seems important to us not to consider that debiaising strategies, several of which are described in the article by Schiff and colleagues, will systematically be associated with an improvement in the quality of the diagnostic process and performance. In addition to the recommendations by Schiff and colleagues, it should be stressed that training has an important role to play in improving diagnostic performance, as it determines how students’ knowledge will organize in long-term memory. It could also be a determining factor in transforming the physician’s relationship to uncertainty, as part of the development of a “New science of uncertainty”, as suggested by the authors (1). The challenge is to reduce physicians’ intolerance to uncertainty, an important factor in overprescribing diagnostic tests. 1. Schiff GD, Martin SA, Eidelman DH, Volk LA, Ruan E, Cassel C, et al. Ten Principles for More Conservative, Care-Full Diagnosis. Ann Intern Med. 2018 Nov 6;169(9):643-646. 2. Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016 May;353:i2139. 3. Croskerry P. When I say… cognitive debiasing. Med Educ. 2015 Jul;49(7):656–7. 4. Norman GR, Monteiro SD, Sherbino J, Ilgen JS, Schmidt HG, Mamede S. The Causes of errors in clinical reasoning: Cognitive biases, knowledge deficits, and dual process thinking. Acad Med. 2017 Jan;92(1):23–30. 5. Ilgen JS, Bowen JL, McIntyre LA, Banh KV, Barnes D, Coates WC, et al. Comparing diagnostic performance and the utility of clinical vignette-based assessment under testing conditions designed to encourage either automatic or analytic thought. Acad Med. 2013 Oct;88(10):1545–51. 6. Sherbino J, Dore KL, Wood TJ, Young ME, Gaissmaier W, Kreuger S, et al. The relationship between response time and diagnostic accuracy. Acad Med. 2012 Jun;87(6):785–91.
James L. Meisel, MD, MHPE, FACP
Associate Professor, Boston University School of Medicine
November 19, 2018
Care-Full Diagnosis: Springboard to What Really Matters
"Ten Principles for More Conservative, Care-Full Diagnosis" is much more than a perspective piece. As intended, its authors incorporate not just principles of decreasing diagnostic harm but highlight the dearth of time to accomplish what matters to patients and caregivers; the need for clinical reasoning to precede diagnostic testing; and the central roles of continuity, humility, and trust in the doctor-patient relationship. I offer that the article should be considered a landmark publication, to be actively taught and broadly reflected upon within undergraduate and graduate medical education.
Schiff GD, Martin SA, Eidelman DH, Volk LA, Ruan E, Cassel C, et al. Ten Principles for More Conservative, Care-Full Diagnosis. Ann Intern Med. ;169:643–645. doi: 10.7326/M18-1468
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Published: Ann Intern Med. 2018;169(9):643-645.
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