Clinical diagnosis in the age of COVID-19

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A guest column by the American College of Physicians, exclusive to KevinMD.

Making an accurate clinical diagnosis is one of the most important things physicians can do for their patients.

But being able to do so is not an easy process to begin with.  It takes years of preparation in learning as much medicine as you can and developing and honing your clinical skills, ranging from taking an effective history and performing an evidence-based physical examination to appropriately interpreting clinical data such as laboratory and imaging studies.  It also requires an understanding of the clinical reasoning process and its potential pitfalls, including knowing the best pathways of thought to use in different clinical circumstances and recognition of our own flaws in the diagnostic reasoning process.  Then there are the more “artistic” elements of diagnosis that involve the application of all these things to a specific patient, incorporating them as active participants into the process and applying diagnostic reasoning in a thoughtful, logical, and intentional manner that considers their unique circumstances and desires.  And this is not to mention additional patient-related and systemic factors that can make achieving a correct diagnosis even more complicated.

It’s therefore no wonder that learning to become an effective diagnostician requires not only years of training, but also an accumulation of clinical experience to refine an already complex task.  Yet, even under usual circumstances, we probably aren’t as good at making accurate diagnoses as we should be, with evidence suggesting that we fail in this endeavor at least 10% of the time. And now the coronavirus pandemic and its effect on the way we are now practicing medicine has certainly made the process of making accurate clinical diagnoses even more challenging than it always has been.

Several of the pandemic’s effects on the diagnostic process are obvious.  The rapid pivot to telemedicine and shift away from in-person encounters to more safely interact with patients certainly impairs our ability to obtain necessary clinical information to inform the diagnostic process.   It may be difficult to elicit the level of detail about a particular symptom or complaint via electronic means, and gathering often critical physical examination information to help make an accurate diagnosis may simply not be possible.

Similarly, infection control measures may make it more challenging to obtain diagnostic information as well.  The need for both clinicians and patients to wear personal protective equipment may decrease the ability to take as detailed or focused histories and physical examinations, potentially decreasing valuable information needed to make an accurate diagnosis.  And limiting both the frequency and length of contact with patients may also impair the diagnostic process by making it more difficult to spend time at the bedside and evaluate clinical symptoms.

But there are additional potential significant impacts on the diagnostic process posed by the pandemic that affect both clinicians and patients.

For clinicians, pandemic-related changes in practice routines due to infection control protocols or an overload of critically ill patients may lead to fatigue, stress, and burnout that can adversely affect the ability to make effective diagnostic decisions which require careful, intentional thought made more difficult by these changes.

And because COVID-19 is a new disease about which our clinical knowledge is rapidly evolving, we run the risk of making a number of potential cognitive errors in our diagnostic decision making.  We may not recognize the illness when it is present in a patient with respiratory symptoms, particularly if we have not yet encountered a significant number of cases and fail to differentiate it from other common viral illnesses; this is further complicated by the difficulty in obtaining rapid, accurate and reliable tests for the infection.  We may also run the risk of failing to make the diagnosis of COVID-19 in patients with a syndromic presentation of the infection about which we are currently learning, such as those with primarily nonrespiratory symptoms (such as anosmia or gastrointestinal complaints).  Conversely, because of the preeminent focus on coronavirus during the pandemic, we may fail to consider other non-COVID-19 conditions responsible for presenting symptoms (such as bacterial pneumonia or sinusitis) by attributing them to likely SARS-CoV-2 infection.  And in those with actual COVID-19, we may also either not recognize complications of the infection that are just emerging (such as coagulopathy) or may potentially attribute new or different symptoms that may be due to an additional, unrelated diagnosis to the underlying coronavirus infection.

For patients, the pandemic may cause them to avoid seeking acute care for significant symptoms such as chest pain or stroke symptoms due to fear of the risk of infection, with accumulating data showing a reduction in admissions and increased morbidity and mortality associated with these diagnoses since the start of the pandemic.  And patients have also been avoiding routine general medical and specialty care, including screening procedures, for this same reason.  The long-term outcomes of delayed and potentially missed diagnoses associated with this avoidance of care will undoubtedly be significant.   Additionally, the pandemic has clearly exacerbated many of the pre-existing health inequities in our system that carry over to the diagnostic process.

However, despite these challenges to accurate diagnosis posed by the pandemic, we have an opportunity to overcome these obstacles and work to further develop and refine our diagnostic skills.

Beyond the many things that will need to occur at the systems level to ensure accurate diagnosis and the safety of our patients, including supporting clinicians during times of pandemic-related stress to allow them the bandwidth to focus on the diagnostic process, applying technology to assist with some elements of the diagnostic process such as symptom tracking and risk assessment, and implementing standardized safety practices and protocols to low resumption of more routine medical care practices, there is much we can do as individual clinicians to ensure accurate diagnoses.

We need to creatively adapt our clinical skills to compensate for the pandemic-imposed changes to the diagnostic process.  For example, the loss of certain types of diagnostic information, such as visual and facial cues and the ability to perform a more extensive physical examination, need to be replaced by other methods for gaining this important information, such as learning to ask the most effective diagnostic questions and using the highest yield, evidence-based examination methods that can be applied within these care limitations.   We can also leverage technology to our diagnostic advantage.  Telemedicine, despite its many limitations, gives us a glimpse into our patient’s personal lives and home setting which may provide important diagnostic information, and the less “clinical” nature of those encounters seems to help patients feel more comfortable in engaging as partners in the diagnostic process.  We also need to understand the shifts in our diagnostic decision making that are required by the pandemic.  A good example is the need to be more selective in deciding between those whose care can safely be provided by alternative means (such as telemedicine) from those who needs to be seen for an in-person visit, despite the associated risks during a pandemic, to ensure diagnostic accuracy.

But perhaps most importantly, we need to intentionally focus on our diagnostic thinking in these disrupted and sometimes chaotic times.  This involves examining our own clinical decision making and the potential biases that may affect our diagnostic accuracy, and consciously applying actions known to help facilitate “getting it right,” such as taking a “diagnostic timeout” to make sure we are considering all of the potential options with our patients.

By seizing this opportunity to advance and enhance our diagnostic skills under the current circumstances, we will not only become more astute diagnosticians now, but also when the pandemic is over.

Philip A. Masters is vice-president, Membership and International Programs, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

Image credit: Shutterstock.com

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