ALEXANDRIA, Va. -- Internist , says there's one thing he gives his patients that helps them deal with uncertainties in diagnosis: his cell phone number.
"Every patient of mine has my cell phone number," Schiff, who is not a concierge physician, said at the annual meeting here of the Society to Improve Diagnosis in Medicine. That way, if Schiff is taking a "wait-and-see" approach to something, "I [can] tell them, 'If you get worse, call me any time, day or night.'" He also tries to make it easy for patients to come in and see him during office hours if they are worried about something.
Schiff, who is associate director of Brigham and Women's Hospital's Center for Patient Safety Research and Practice, in Boston, told 乌鸦传媒 that he only spends about 25% of his time in clinical practice, but even when he practiced full-time at Cook County Hospital in Chicago, giving patients complete access -- via his home phone number -- was not an issue.
"In 30 years, I can count on one hand the number of [abusive] phone calls," he said. "More often, a patient would go to the emergency room instead, and when I asked them why they didn't call me, they'd say they didn't want to bother me."
Allowing for uncertainty in diagnosis is just one part of a practice style that Schiff is calling "conservative diagnosis" -- a term that means more than just ordering fewer tests. "We need to do the right thing for the right reason," he said. "We don't just need fewer tests, but also more appropriate testing and better care."
Conservative diagnosis is based on respect for clinical challenges, uncertainties, anxieties, and ways clinicians and patients can work together to improve care and outcomes, he said, noting that the idea was an outgrowth of a similar movement called "conservative prescribing" that Schiff and colleagues .
Conservative diagnosis starts with the fundamentals of diagnosis:
- Establishing a differential diagnosis
- Listening to the patient and obtaining a good history
- Doing a careful exam
- Matching the syndrome to the findings
- Understanding of the limitations of diagnostic tests
- Avoiding known biases
- Using Bayesian probability weighing
Those are then combined with four paradigms:
- Precautionary principle. "Instead of saying we're going to figure out the risk and benefit of new drug, procedure, or test, we're going to err on the side of being cautionary," said Schiff. "We want to see the evidence that this is safe."
- Primary care principles. "Primary care is not calling the shots in American medicine; it's not what doctors are going into, but we need to emphasize things like continuity of care and caring relationships," as well as teamwork, he said.
- Key patient safety lessons. This includes situational awareness of pitfalls as well as "safety nets" to mitigate inevitable errors, and promoting a culture of safety, according to Schiff.
- Critique of market medicine and a market mindset. This means maintaining a healthy skepticism to avoid favoring overuse of tests, as well as looking at things from a longer-term time horizon.
"We have to have a new way of thinking about patients and caring," Schiff said. "The previous idea was that if I really care about the patient, I'm going to get a lot of tests ... Rather, it has to be more patient-centered based on concerns, outcomes, and hearing from the patient."
Contrary to popular belief, "There are a lot of patients who want to be conservative about drugs and tests," he said. "We think all patients want is more x-ray and MRIs and drugs, but it turns out it's not true."
Also, physicians should listen to what they're telling their patients in terms of stigmatization, medicalization, and validation. "If a patient comes in and has back pain or a headache, and you say 'It's all in your head, there's nothing wrong with you,' then [that patient] is going to want an MRI, rather than if you gave them a better explanation of what you think is going on," said Schiff.
"We have to deal with the fact that we're dealing with uncertainty here," he added. "And we have to recognize the anxiety -- a lot of patients will say, 'Just give me the answer.'"
Getting feedback from patients is also important, Schiff said. "Feedback allows you to have a differential diagnosis; they go hand in hand. I'm going to keep a lot of doors open -- cell phone and office -- rather than slamming doors and saying, 'There's nothing wrong with you' or 'You definitely have X or Y.' We need to think about how to hardwire feedback, invite feedback, and facilitate feedback."
Physicians also need to be taught more about nonspecific symptoms, according to Schiff. In with nonspecific symptoms like back pain, headache, and insomnia, testing was performed on 2/3 of the patients, and researchers found organic etiology in only 16%.
"These are things we may not be able to get to the bottom of, and we have to think about how to approach them better," said Schiff. "We have to disconnect this idea [that] every time somebody has a symptom we're going to send them to for a workup or to a specialist."
Finally, there is continuity of relationships, he said. "Patients are not going to agree to defer workups and testing if they don't have a relationship with you and trust you and aren't going to follow-up with you. We need to have this diagnostic alliance ... It needs to be based on trust and time and continuity."