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2 The Diagnostic Process
Pages 31-80

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From page 31...
... It also highlights the mounting complexity of health care, due to the ever-increasing ­ ptions for diagnostic testing2 and treatment, the rapidly rising levels o of biomedical and clinical evidence to inform clinical practice, and the frequent comorbidities among patients due to the aging of the popula 1  Inthis report, the committee employs the terminology "the diagnostic process" to convey diagnosis as a process. 2  The committee uses the term "diagnostic testing" to be inclusive of all types of testing, including medical imaging, anatomic pathology, and laboratory medicine, as well as other types of testing, such as mental health assessments, vision and hearing testing, and neurocognitive testing.
From page 32...
... Performing a clinical history and interview, conducting a physical exam, performing diagnostic testing, and referring or consulting with other clinicians are all ways of accumulating information that may be relevant to understanding a patient's health problem. The information-gathering approaches can be employed at different times, and diagnostic information can be obtained in different orders.
From page 33...
... FIGURE 2-1  The committee's conceptualization of the diagnostic process. 33 Figures S-1 and 2-1 raster image, not editable broadside
From page 34...
... , and whether a single diagnosis is appropriate. When considering invasive or risky diagnostic testing or treatment options, the
From page 35...
... If the diagnostic team members are not satisfied that the necessary information has been collected to explain the patient's health problem or that the information available is not consistent with a diagnosis, then the process of information gathering, information integration and interpretation, and develop
From page 36...
... This also illustrates the need for clinicians to diagnose health problems that may arise during treatment. The committee identified four types of information-gathering activities in the diagnostic process: taking a clinical history and interview; performing a physical exam; obtaining diagnostic testing; and sending a patient for referrals or consultations.
From page 37...
... . An accurate history facilitates a more productive and efficient physical exam and the appropriate utilization of diagnostic testing (Lichstein, 1990)
From page 38...
... . Diagnostic Testing Over the past 100 years, diagnostic testing has become a critical feature of standard medical practice (Berger, 1999; European Society BOX 2-2 Laboratory Medicine, Anatomic Pathology, and Medical Imaging Pathology is usually separated into two disciplines: laboratory medicine and anatomic pathology.
From page 39...
... In many cases, diagnostic testing can identify a condition before it is clinically apparent; for example, coronary artery disease can be identified by an imaging study indicating the presence of coronary artery blockage even in the absence of symptoms. The primary emphasis of this section focuses on laboratory medicine, anatomic pathology, and medical imaging (see Box 2-2)
From page 40...
... Errors related to diagnostic testing can occur in any of these five phases, but the analytic phase is the least susceptible to errors (­ ichbaum et al., 2012; Epner et al., 2013; Laposata, 2010; Nichols and E Rauch, 2013; Stratton, 2011) (see Chapter 3)
From page 41...
... . The task of selecting the appropriate diagnostic testing is challenging for clinicians, in part because of the sheer volume of choices.
From page 42...
... . Molecular diagnostic testing is expected to improve patient management and outcomes.
From page 43...
... . Molecular diagnostic testing presents many regulatory, clinical practice, and reimbursement challenges; an Institute of Medi cine study is looking into these issues and is expected to release a report in 2016 (IOM, 2015b)
From page 44...
... manages the Clinical Laboratory Improvement Advisory Committee (CLIAC) , a body that offers guidance to the federal government on quality improvement in the clinical laboratory and revising Clinical Laboratory Improvement Amendments (CLIA)
From page 45...
... The Joint The Joint Commission accreditation ensures the safety and quality of Commission laboratories and satisfies CLIA requirements (The Joint Commission, 2015)
From page 46...
... . Like other forms of diagnostic testing, medical imaging has limitations.
From page 47...
... . There are four CMS-designated accreditation organizations for medical imaging: ACR, the Intersocietal Accreditation Commission, The Joint Commission, and RadSite (CMS, 2015a)
From page 48...
... . IMPORTANT CONSIDERATIONS IN THE DIAGNOSTIC PROCESS The committee elaborated on several aspects of the diagnostic process which are discussed below, including • d  iagnostic uncertainty • t  ime • p  opulation trends • d  iverse populations and health disparities • m  ental health Diagnostic Uncertainty One of the complexities in the diagnostic process is the inherent uncertainty in diagnosis.
From page 49...
... Included in these assessments are the potential for false positives and ambiguous or slightly abnormal test results that lead to further diagnostic testing or unnecessary treatment. There are some cases in which treatment is initiated even though there is limited certainty in a working diagnosis.
From page 50...
... The thousands of different diseases and health conditions do not present in thousands of unique ways; there are only a finite number of symptoms with which a patient may present. At the outset, it can be very difficult to determine which particular diagnosis is indicated by a particular combination of symptoms, especially if symptoms are nonspecific, such as fatigue.
From page 51...
... Consequently, the threshold for ordering diagnostic testing or for initiating treatment becomes quite low for such health problems (Pauker and Kassirer, 1975, 1980)
From page 52...
... Patients with mental health–related symptoms may also be more vulnerable to diagnostic errors, a situation that is attributed partly to clinician biases; for example, clinicians may disregard symptoms in patients with previous diagnoses of mental illness or substance abuse and attribute new physical symptoms to a psychological cause (Croskerry, 2003a)
From page 53...
... and involves judgment under uncertainty, with a consideration of possible diagnoses that might explain symptoms and signs, the harms and benefits of diagnostic testing and treatment for each of those diagnoses, and patient preferences and values. The current understanding of clinical reasoning is based on the dual process theory, a widely accepted paradigm of decision making.
From page 54...
... . Hypothetico-deductivism is an analytical reasoning model that describes clinical reasoning as hypothesis testing (Elstein et al., 1978, 1990)
From page 55...
... . Broadly construed through a pattern-rec ognition framework, nonanalytical models attempt to understand clinical reasoning through human categorization and classification practices.
From page 56...
... . There are many heuristics and biases that affect clinical reasoning and decision making (see Table 2-2 for medical and nonmedical examples)
From page 57...
... Search satisficing, also The emergency department We want a plane ticket that known as premature clinician seeing a patient costs no more than $1,000 closure, is the tendency with recent onset of low back and has no more than one to accept the first pain immediately settles on connection. We perform an answer that comes a diagnosis of lumbar disc online search and purchase along that explains disease without considering the first ticket that meets the facts at hand, other possibilities in the these criteria without without considering differential diagnosis.
From page 58...
... . System 1 and system 2 perform optimally in different types of clinical practice settings.
From page 59...
... . Croskerry and colleagues provide a framework for understanding the cognitive activities that occur in clinicians as they iterate through information gathering, information integration and interpretation, and determining a working diagnosis (Croskerry et al., 2013)
From page 60...
... This process is repeated for each condition in the differential diagnosis and may be augmented by additional sources of information, such as diagnostic testing, further history gathering or physical examination, or referral or consultation. The cognitive process of reassessing the probability assigned to each potential diagnosis involves inductive reasoning,5 or going from observed signs and symptoms to the likelihood of each disease to determine which hypothesis is most likely (Goodman, 1999)
From page 61...
... The way in which information is processed through system 1 and system 2 informs a clinician's subsequent diagnostic performance. Figure 2-3 illustrates the concept of calibration, or the process of a clinician becoming aware of his or her diagnostic abilities and limitations through feedback.
From page 62...
... . Probabilistic reasoning is most often considered in the context of diagnostic testing, but the presence or absence of specific signs and symptoms can also help to rule in or rule out diseases.
From page 63...
... Age It is likely that clinician age has an impact on clinical reasoning abilities (Croskerry and Musson, 2009; Eva, 2002; Singer et al., 2003; Small, 2001)
From page 64...
... . Personality, Physical State, and Gender Individual personality influences clinical reasoning and decision making ( ­ Croskerry and Musson, 2009)
From page 65...
... While most clinicians will not formally calculate probabilities, the logical principles behind Bayesian reasoning can help clinicians consider the trade-offs involved in further information gathering, decisions about treatment, or evaluating clinically ambiguous cases (Kassirer et al., 2010)
From page 66...
... . THE DIAGNOSTIC EVIDENCE BASE AND CLINICAL PRACTICE Advances in biology and medicine have led to improvements in prevention, diagnosis, and treatment, with a deluge of innovations in diagnostic testing (IOM, 2000, 2013a; Korf and Rehm, 2013; Lee and Levy, 2012)
From page 67...
... , health care professionals have difficulty keeping up with the breadth and depth of knowledge in their specialties. For example, to remain up to date, primary care clinicians would need to read for an estimated 627.5 hours per month (Alper et al., 2004)
From page 68...
... . CPGs can include diagnostic criteria for specific conditions as well as approaches to information gathering, such as conducting a clinical history and interview, the physical exam, diagnostic testing, and consultations.
From page 69...
... . With the growth of diagnostic testing and substantial geographic variation in the utilization of these tools (due in part to the limitations in the evidence base supporting their use)
From page 70...
... 2008. The development of clinical reasoning ex pertise; Implications for teaching.
From page 71...
... 2009a. Clinical cognition and diagnostic error: Applications of a dual process model of reasoning.
From page 72...
... 2013. When diagnostic testing leads to harm: A new outcomes-based approach for laboratory medicine.
From page 73...
... 2011. Multiple clinical practice guidelines for breast and cervical cancer screening: perceptions of U.S.
From page 74...
... 2011. Application of GRADE: Making evidence-based recommendations about diagnostic tests in clinical practice guidelines.
From page 75...
... 2010. Learning clinical reasoning.
From page 76...
... 2013. Ensuring the integrity of clinical practice guidelines: A tool for protecting patients.
From page 77...
... 2010. Diagnostic error and clinical reasoning.
From page 78...
... Presen tation to the Committee on Diagnostic Error in Health Care, August, 7, 2014, Wash ington, DC. Schiff, G
From page 79...
... : Are "cognitive biases plus" underlying the EBM paradigm respon sible for undermining the quality of evidence? Journal of Evaluation in Clinical Practice 20(6)
From page 80...
... 2009. Scientific evidence underlying the ACC/AHA clinical practice guidelines.


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