By definition, diagnosis is “the identification of the nature of an illness or other problem by examination of the symptoms.” Unfortunately, that is akin to saying that cooking is the process of examining the ingredients. As a result, there is a tendency to rush to treatment when the symptoms are obvious. When the treatment is not effective or the symptoms are less than obvious, the definition of diagnosis does not prescribe what to do next. Our education system, from childhood through medical school, leaves doctors ill-prepared for what comes next. In fact, Brian Mastroianni points out, in a Healthline article, that 40,000 to 80,000 people in the U.S. alone die every year from complications due to misdiagnosis. This is not acceptable.
Without the proper training required to solve challenging medical concerns, the void is often filled by four instinctual human behaviors. These behaviors include:
Chasing a theory: Essentially looking for a penny in the corner of a round room.
Chasing the wrong problem: Failing to revisit facts and consider alternative sources of the underlying problem.
Implementing workarounds: Treating urgent symptoms is critical, but failure to ultimately follow through to determine the underlying root cause is extremely risky.
Blame and fingerpointing: When an underlying diagnosis falls into a gray area between disciplines the result is often fingerpointing or, worst case, blame.
Solving a challenging diagnosis is a learning process. This learning process, to be successful, must include a leader, the patient, and the proper experts working collaboratively in a shared space (physical or virtual). The leader should facilitate the learning process via the disciplined execution of a proven problem-solving methodology. The leader can be any party at the table, although it is more commonly either the patient themselves or a primary care physician or nurse practitioner. The leader is the individual who is primarily concerned with learning the correct patient diagnosis as quickly as possible regardless of their own subject matter expertise. In other words, the leader assumes ownership of the definitive root cause as opposed to treatment of a specific occurrence of the issue. The patient can be the leader when they understand that diagnosing challenging medical problems is not a spectator sport, but there is also an opportunity for primary care and advanced practice clinicians to assume the leadership role. This opportunity is evidenced in the January 2022 article, “10 Physician Trends to Know in 2022” from Merritt Hawkins. They specifically highlight the following trends:
- Medical practices need to become more consumer-oriented.
- Physician demand is greater than the supply.
- Advanced practice clinicians provide primary care.
- Cost reductions and value-based care.
The overall trend is to move the patient to the lowest cost care model possible. This does not have to mean the quality of care is impacted. In fact, with the proper leadership skills and tools, the result could be a win-win for all parties.
Whether led by the patient or by a primary care physician or nurse practitioner, a proper leadership-based problem-solving methodology is a critical tool. The approach itself is not nearly as important as the discipline to use a formal approach. One approach, for example, is a simple, proven framework that, on average, leads to a significant reduction in the time to resolve problems. The framework consists of the following seven steps:
1. Assemble the team. Invite approximately three practice area experts into the discussion. More can be added as deemed necessary.
2. Train the team on the process to be used. This can simply be a discussion, but setting the stage for a disciplined approach is critical.
3. Document the problem statement and confirm agreement. A problem statement must clearly state what is not working. For example, you will not record “the tire is flat.” You will record, “the tire is not holding air.” Focus on what is not working as opposed to what is visually obvious.
4. Document all known facts. Facts are indisputable truths that can be confirmed or observed. Take nothing for granted. Don’t be afraid to say, “can you prove that?”
5. Document all questions. Ignore no question. Failure to listen to all input will shield you from the learning process in a cloak of arrogance.
6. Assign the outstanding questions to experts and ask them to update the shared space as they discover answers. The leader will approve all new proposed facts before they are considered facts.
7. Document all new facts and cycle back through the process from step 3, where you will revisit the problem statement. Repeat until you learn the true root cause. Revisiting the problem statement at the beginning of each iteration is a vital step to ensure that all parties are on the same page. You do not want to revisit old theories that are no longer associated to the corrected problem statement.
If this message is heard and received by enough patients, doctors, clinicians, and nurse practitioners perhaps we can move the needle by 1 percent. A 1 percent decrease in deaths from complications due to misdiagnosis would be 400 to 800 lives saved in a year. That is still not acceptable, but it may be the spark that is needed to ignite systemic change.
Jim Sholler is a consultant and author of Solved in 7: The Power of Disciplined Problem-Solving.
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