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Reference: Schiff, G. D., Martin, S. A., Eidelman, D. H., Volk, L. A., Ruan, E., Cassel, C., … Sheikh, A. (2018). Ten principles for more conservative, care-full diagnosis. Annals of internal medicine, 169(9), 643-645.

This week’s paper of the week is brought to you by Professor Sir Muir Gray, 3V’s Founding Director.

Bottom line, chosen by Muir from the paper

Evidence increasingly shows that indiscriminate diagnostic testing and referrals often fail to provide definitive explanations or improve outcomes and at times are more harmful than beneficial…

…Medicine currently shortchanges the patient history and physical examination, even though carefully listening to and observing patients over time often provide more valuable information than multiple radiologic or chemical tests. We must stop equating testing with caring and thoroughness and instead emphasize respectful listening, examination, follow-up, and collaboration with the patient to “coproduce” diagnoses

Here are the ten key principles:

  1. Promoting enhanced caring and listening
  2. Developing a new science of uncertainty
  3. Rethinking symptoms
  4. Maximizing continuity and trust
  5. Taming and taking time
  6. Linking diagnosis to treatment
  7. Ordering and interpreting tests more thoughtfully
  8. Safety nets: incorporating lessons from diagnostic errors
  9. Addressing cancer: fears and challenges
  10. Diagnostic stewardship: transforming the role of specialists and emergency department clinicians; Implicit in conservative diagnosis is minimizing indiscriminate use of specialty referrals and emergency departments. However, both specialists and emergency department clinicians can positively contribute by leveraging their knowledge and playing stewardship roles.

Implications for value improvement 

A paradigm shift is taking place in the medical profession, or at least in the leadership who are helping articulate the new paradigm of clinical practice which has been called interpersonal or empathic or personal value medicine. As always the new paradigm embraces and enfolds the previous evidence based paradigm, although it should be recognised that the original definition of EBM emphasised the need for personal preferences to be taken into account as well as evidence. (1)

The other side of the coin, from the focus on personal value, is the need for the medical profession to focus on the population perspective. The key term emerging is the role of the clinical professions in stewardship, (2) first emphasised in the Academy of Medical Royal Colleges’ report on value which stated that:

A cultural shift is required which calls upon doctors and other clinicians to ask, not if a treatment or procedure is possible, but whether it provides real value to the patient and genuinely improves the quality of their life or their prospects for recovery (2,3)

References:

  1. Walking Away from Conveyor-Belt Medicine

Fabrizio Elia, M.D., and Franco Aprà, M.D. Walking Away from Conveyor-Belt Medicine. n engl j med 380;1 nejm.org January 3, 2019 pp8-9 

 

  1. The Time for Opioid Stewardship Is Now

Joint Commission Journal on Quality and Patient Safety 2019; 45:1–2. Friedhelm Sandbrink, MD; Raj Uppal, MD

 

  1. Academy of Medical Royal Colleges (2014)

Protecting resources and promoting value