DOI 10.
1515/dx-2013-0009 Diagnosis 2014; 1(1): 107–109
Jason Maudea,*
Differential diagnosis: the key to reducing
diagnosis error, measuring diagnosis and a
mechanism to reduce healthcare costs
Abstract: Differential diagnosis has been taught in medi- part of an institution’s overall quality score. But, until all
cal schools for over 100 years and yet it is not routinely healthcare institutions have sophisticated EMR systems
carried out in practice; nor is it required to be documented and recognised standards for the speed of diagnosis,
within medical notes. I strongly believe that the routine appropriateness of test ordering, referrals and admis-
use of a differential diagnosis would not only substan- sions for all diseases, measurement will not be practical.
tially reduce the level of diagnostic error but would also In reality, the routine measuring of diagnostic accuracy is
greatly reduce the cost of healthcare. This solution to the very unlikely to happen for many years.
seemingly intractable problems of diagnostic error and In spite of the many patient safety and quality of
rising healthcare costs is simple and has been with us for care initiatives over the last 14 years (dating back to the
100 years! landmark Institute of Medicine report ‘To Err is Human’),
the performance of the crucial process of diagnosis and
Keywords: diagnostic decision support; diagnostic error; its related functions has been relegated to the ‘too dif-
differential diagnosis; symptom checker. ficult to fix’ bucket primarily due to the difficulties in
measurement.
With research acknowledging that the greatest pre-
a
The author is founder of Isabel Healthcare, a company which
produces diagnosis decision support tools for clinicians and patients.
dictor of diagnostic accuracy is a differential diagnosis
*Corresponding author: Jason Maude, Isabel Healthcare, that includes what turns out to be the correct diagnosis
Meadowbrook, Bunch Lane, Haslemere, GU27 1AE, UK, [4], should we not be insisting that a differential diagno-
E-mail:
[email protected] sis is worked up for every patient and documented in the
medical notes? With modern diagnosis decision support
tools now able to help the clinician build a differential
William Osler is credited with introducing the disci- diagnosis in seconds or minutes, this would be easy,
pline of differential diagnosis over a hundred years ago. cheap and practical to implement.
In essence, this is simply a trigger and structure for a The lack of a simple measure for diagnosis will always
methodical way of thinking. be there as an excuse for healthcare not to address this
Clinicians will debate how much of medicine is art and important problem. We should, therefore, be introducing
how much is science but interestingly “Osler’s medical art a practical proxy now rather than waiting several years
was informed and controlled by all the assistance science before the technology is in place to introduce more accu-
could give. He did not discuss diagnosis as a matter of rate measures.
intuition. Every scientific aid was welcome” according to The obligation to compile a differential could act
the author of Osler’s biography: ‘A Life in Medicine’ [1]. as a vital trigger to stimulate thinking at the time of the
There is now a good body of evidence to show the consultation.
quantum of diagnostic error and why it happens. Time The disappearance of the routine use of the differen-
after time, research papers conclude that the clinicians tial diagnosis, the increasing degree of specialisation and
who committed the error should have broadened their dif- availability of lab tests and imaging coupled with the fee
ferential diagnosis or compiled and documented one in for service payment model has conspired to reduce the
the first place [2, 3]. time and incentive to think. Doctors have been seduced
Why, despite this vast body of evidence in favour of by the easy availability of increasingly sophisticated
differential diagnosis, is it still not obligatory? In order tests and the illusion of precision afforded by the pleth-
for diagnosis to become a mainstream quality and patient ora of data. However, in spite of all the sophisticated
safety issue, it is vital that it can be measured and, there- tests available the reality is that diagnostic performance
fore, included as a quality metric that would become has not improved significantly and healthcare costs have
108 Maude: Differential diagnosis: the key to reducing diagnosis error
risen inexorably. A recent study in JAMA looking at diag- that more than 80% of newly admitted internal medicine
nostic accuracy showed barely any improvement con- cases could be correctly diagnosed on admission based on
tributed by lab tests and imaging after the history and history and physical alone [7]. The patient is the expert
physical stage [5]. on his own symptoms and, in the model described above,
The reality today is that family physicians order tests should be considered an active participant in helping to
in 29% of all patient visits, ED physicians for 41% of all compile the core differential diagnosis. The patient should
visits and general internists for 38% of all visits. Since be encouraged to research his own diagnosis by using a
only 34% of visits to primary care are for a new complaint symptom checker to help him articulate clearly what his
this means that, in reality, tests are probably ordered for most bothersome symptoms are and to contribute to a dis-
almost every new visit [6]. Anecdotal stories of an aston- cussion on the differential diagnosis rather than remain-
ishing 30%–50% of referrals being inappropriate and hos- ing a passive part of the diagnostic process.
pitalists ordering 10 consults for patients who have been Rarely has such a complex and expensive problem
in the hospital for 2 days without a diagnosis show that the had a solution that is inexpensive, simple and, curiously,
current practice is wasting clinicians’ time and patients’ has already been part of basic training for over 100 years.
time and money while also running the risk of delays in Differential diagnosis is a trigger for disciplined and
diagnosis. This is untenable and has to change. Tests and methodical thinking that has been shown to be the most
investigations have now become a substitute for thinking. accurate indicator of diagnostic accuracy. It is a viable,
Thinking takes time so when time is short it’s much easier cost-effective and practical proxy for the measurement of
and quicker to order tests and consults. diagnosis which could make it a workable quality score.
The problem clinician leaders face now is that, just Lastly it could be a tool to filter and streamline the order-
as the Affordable Care Act changes the way healthcare ing of consults and lab tests, contributing to a significant
is paid for from by volume to value or simply for looking reduction in costs and time.
after people and doing the right thing, a generation of The routine use of the differential diagnosis which
doctors has grown up accustomed to doing things rather has gradually faded over the last 50 years due to lack of
than thinking. clinician time and, frankly clinicians’ inability to quickly
The requirement for a differential diagnosis would and accurately recall and synthesise vast amounts of data
act as a trigger to start and structure thinking. It would is now made possible by the new generation of highly
also make doctors’ lives easier: the plethora of data from sophisticated diagnosis decision support tools that can
lab tests currently means that doctors have to make even work automatically in the background suggest-
sense of perhaps 10 data points rather than the 2–3 at ing possible diagnoses when needed. With an estimated
the outset based just on the clinical features. The differ- 80,000–160,000 patients in US hospitals alone (2–4
ential diagnosis serves to filter data meaning that tests million globally) suffering death or disability each year
or specialist consults are only ordered to confirm a high from potentially preventable diagnostic error [8] and
probability diagnosis in the differential. As it engenders healthcare costs rising inexorably, how much longer can
greater objectivity, it also serves to help refute competing the industry stand by and ignore the problem, especially
hypotheses. when a simple solution has been in their midst for so long?
It remains a truism that if you listen to your patient
they will tell you the diagnosis. The old adage is that 75%– Conflict of interest statement: The author declares no
80% of the diagnosis is revealed by the patient’s story and conflict of interest.
should then be confirmed by judiciously ordered tests.
This adage was proven in an ED based study which found Received September 9, 2013; accepted October 27, 2013
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