Ideas on improving rates of missed/delayed diagnoses in PCP type visits.

Mon Jan 20 18:12:02 UTC 2014

Hey guys,

The ongoing discussion somehow suggests that diagnosis is difficult in a majority of patients. I want to add some perspective.

In a practice setting such as a pediatric ED (both tertiary care and a community ED) where I practice, diagnosis is pretty straight forward for the vast majority of patients (>95%, I would think), and using any extra tools would likely do more harm than good (generating unneeded lists of differential diagnoses, pressure to disprove them by testing, adding to expense, time spent in the ED, discomfort/pain from IV insertion, potential exposure to unneeded radiation, false positive results resulting in more confusion than at the start of the process, etc.)

The vast majority of patients and their families are rational, but we have to acknowledge the increasing prevalence of patients with psychosomatic disorders, who are looking to find an organic basis for their complaints, and sometimes having partial knowledge, driving unneeded testing!

The same may be true of many clinicians who order unnecessary tests, sometimes with good intentions of arriving at a diagnosis, but increasingly to rule out diseases for fear of being sued in case any thing was missed, and sometimes to satisfy families -"educated, informed consumers", who wouldn't be swayed by rational explanation.

Thinking of a  differential diagnosis in nearly every case is useful (one may not prospectively know the cases where diagnosis is going to be difficult or wrong), using a Bayesian approach during the work-up of a case with some uncertainty very useful, but overdoing this with an extensive list of differential diagnoses may cause its own problems.


Manoj K. Mittal, MD
Attending Physician
Division of Emergency Medicine
The Children's Hospital of Philadelphia
Associate Professor of Clinical Pediatrics
Perelman School of Medicine, University of Pennsylvania
Philadelphia, PA

From: Bob Latino [blatino at RELIABILITY.COM]
Sent: Monday, January 20, 2014 11:34 AM
Subject: Re: [IMPROVEDX] Ideas on improving rates of missed/delayed diagnoses in PCP type visits.

Great discussion.

I would think that both parties should have the shared goal of a positive outcome.

I know when someone in my family has certain symptoms that are outside the norm for a typical cold (as one example), I use an app called 'iTriage' (  I often wondered if physicians laugh at the credibility of such information resources made easily available to patients.

I realize this is not equivalent to any formal diagnosis from an experienced physician, but it may give me ideas about a range of possible diagnoses and interim actions I can take right now. Would it seem logical that a group of medical professionals had to develop the cause-and-effect logic to put this type of app together, based on experience from a broad base of patient interactions/outcomes.

What do doctors feel about the typical layman coming into their PCP with information from such sources?

As Victoria states, do they discount it outright because the patient is ‘playing doctor’ using websites? Do they explore the potential validity of the information and then provide reasoning as to why it may not be applicable in their case? If the information is accurate, do they acknowledge so even though it came from ‘the web’?

Does the Pareto Principle apply here where 20% of the typical diagnoses cover 80% of the typical symptoms that patient’s present with (which is what I expect an approach like iTriage is trying to capture)?

The mix on this forum is what provides the greatest value to me in understanding effective decision-making on behalf of the physician as well as the patient.

Robert (Bob) J. Latino


Reliability Center, Inc., P.O. Box 1421, Hopewell, VA  23860

(O) 804.458.0645  (F) 804.452.2119

blatino at l

-----Original Message-----
From: Vic Nicholls [mailto:nichollsvi2 at GMAIL.COM]
Sent: Monday, January 20, 2014 9:53 AM
Subject: Re: [IMPROVEDX] Ideas on improving rates of missed/delayed diagnoses in PCP type visits.

This was another great post John.

Here is a question for doctors: if someone comes in and says I have symptoms X, Y, and Z, and think I have diagnosis A, would the clinician be open to think about the criteria for the diagnosis and say, it is possible but have you explored diagnosis B or C? That would also fit your symptoms. Lets see what other symptoms you have to narrow it down.

This would help in having confidence in the doctor, less reliance on Oprah type diagnoses, and doesn't appear to take a lot of time.

What about something like that? Question for the professionals on here.


On 1/19/2014 10:19 PM, John Brush wrote:

>     I think that the emphasis on “patient-centeredness” has largely focused on therapeutic decisions, and hasn’t adequately addressed diagnostic decision making. There needs to be more engagement. There are problems on both sides of the conversation. Many patients seem to seek the illusion of certainty. Some are biased by dread or wishful thinking. It is hard to be objective when you are the patient. All doctors are patients at some point, and know that they aren’t very good at diagnosing themselves.

>     I think it is a good idea to inform patients about the inherent uncertainty in diagnosis. I often ask patients “what do you think it is?” Sometimes I get a helpful answer. But usually, it least the question serves to get the patient thinking about the imprecision of testing and the difficulty in establishing a firm diagnosis.

>     I think there is one other lurking problem. The malpractice environment has a priming effect that can cause doctors to view patients and their families as potential litigants. Doctors can get defensive when patients ask questions about the diagnosis. Doctors need to recognize that this is usually irrational and they need to work on getting past that priming effect. Also, unfortunately, doctors visits are often too time-pressured to have a decent in-depth conversation.

>     There are a lot of barriers that inhibit getting patients better involved. It would be good to discuss the barriers and bring these impediments to doctor’s attention. I think the vast majority of doctors would like to learn how to better engage patients in diagnostic reasoning. I think helpful feedback and suggestions would be welcomed by virtually all physicians.

> John


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