Dear Dr. Steve| Volume 23, ISSUE 8, P4-5, November 2022

Diagnostic Quality as a Key Quality Improvement Concern

      Dear Dr. Steve: In my facility, our staff and practitioners often struggle with the accuracy and completeness of diagnoses on new admissions. It is often challenging to get the information that is needed, particularly to confirm or update psychiatric diagnoses. Hardly anyone seems to have the time or persistence to update the diagnosis list, even after weeks or months. In addition, it is difficult to keep up with diagnoses in patients with new and recurrent symptoms. What should I do to address these long-standing issues of accurate and complete diagnoses?
      Dr. Steve responds:
      Recently, much has been said about allegedly questionable diagnoses of schizophrenia in individuals with dementia to justify the use of antipsychotics. But the issue of accurate diagnosis is far wider than any one diagnosis. Although this is sometimes alluded to over time, as with schizophrenia and the Patient Driven Payment Model (PDPM), it has rarely been given meaningful attention and discussion in post-acute and long-term care.

      Diagnosis Is a Specific Form of Reasoning and Problem Solving

      A fundamental principle in medicine is that if you get the diagnosis wrong, you’ll probably apply the wrong therapy ... A corollary is that if the therapy isn’t working, increasing the dose may make things worse. —Ed Marsh, “Reflections of a Medical Ex-Practitioner” (Wall Street J, Apr. 7, 2013)
      Humans have a great capacity for problem solving, based on collecting and analyzing information. They also have significant potential to cause or exacerbate problems due to distorted reasoning and inadequate problem-solving efforts.
      It is important to understand how we solve clinical and nonclinical problems, identify causation, and select interventions. The basic steps, which are not unique to medical practice, include gathering, organizing, and analyzing information. For example, auto mechanics and plumbers use similar techniques to identify and address causes of problems. However, medical diagnosis often involves more complex information and can directly impact the life of other human beings to a greater degree than most other jobs or professions.
      A correct diagnosis can save lives and prevent catastrophic complications (E.P. Dalogh et al., eds., Improving Diagnosis in Health Care, National Academies Press, 2015). But inadequate diagnostic effort and incorrect diagnoses may permit a disease to progress or cause significant complications (R.F. LeBlond et al., eds., DeGowin‘s Diagnostic Examination, 11th ed., McGraw-Hill, 2020). Adherence to the full clinical reasoning and diagnostic process (as discussed in my previous columns in Caring) is essential in all but the simplest situations.

      The Art and Skill of Diagnosis

      There have been many efforts over the decades to identify principles of sound clinical problem solving and reasons for diagnostic errors (Trans Am Clin Climatol Assoc 2011;122:290–311). No approach is guaranteed to always get the right or the best answer, but effective clinical reasoning and problem solving can potentially produce the desired results more reliably than other approaches — and with the least possible harm. At the very least they can help avoid potentially inappropriate or problematic treatment.
      Evidence-based diagnosis requires three essential components:
      • Obtaining detailed, patient-specific knowledge;
      • Having substantial topical knowledge;
      • Using skilled clinical reasoning to combine 1 and 2 to draw patient-specific conclusions.
      Effective clinicians also:
      • Know how to interpret symptoms and test results;
      • Have a rationale for ordering diagnostic tests and interpreting results;
      • Seek evidence provided from elsewhere (e.g., hospital transfers and consultants) to confirm their conclusions and diagnoses and recognize that diagnoses made elsewhere may be incomplete or incorrect;
      • Are willing and able to rethink, revise, or discard their initial assumptions based on new evidence.

      Simple and Complex Diagnoses

      Problem solving requires first understanding the nature of the problem (e.g., simple or complex). The diagnostic process has varying degrees of complexity. Simple diagnosis involves a limited number of possibilities, and it doesn’t require sophisticated reasoning. This is similar to simple problem solving in everyday life. For instance, I may guess that my lamp won’t light because the bulb has burned out; I replace the bulb without considering other possible reasons such as a faulty switch or bad wiring; the lamp now works. Many situations in PALTC involve a similarly limited cause identification effort.
      By contrast, complex problem solving in diagnostic practice considers multiple simultaneous causes of common symptoms, and that multiple symptoms can have a common cause. More complex diagnostic effort is necessary when:
      • There are more potential simultaneous medical causes and nonmedical contributing factors;
      • The diagnoses are unclear;
      • The patient is not recovering or improving as anticipated, based on the initial assumptions;
      • The treatment is uncertain or of questionable effectiveness.
      In all but the simplest situations, good diagnosis requires a “thought framework” or a more rigorous approach rather than relying on trial and error or others’ opinions and conclusions.
      Individualizing care requires understanding that similar symptoms in different patients can represent a whole host of different causes and complications. Medical practitioners lead the way in defining symptoms sufficiently and seeking their causes and connections, regardless of whether other team members prompt them to do so.

      Diagnosis Is Everyone’s Business

      A baseball game is not won by playing the game one position at a time. Every player understands the overall objective and process even though they are involved in different ways and at different times. They each are limited by their knowledge and skills; the player on second base doesn’t need to be a good pitcher but does know what pitchers do. A similarly coordinated approach to problem solving in patient care — including cause identification — is needed.
      Effective cause identification in PALTC patients arises from a coordinated effort by all interdisciplinary team (IDT) members with different knowledge and skills to obtain and aggregate accurate and complete information. Each of the participants understands the diagnostic process and their role in it. They each make a competent and relevant contribution to the combined process. They know their limits and try not to exceed them. They have a basic understanding of everyone’s role in the diagnostic process.
      Unfortunately, in many nursing homes, problem solving is limited and compartmentalized. For example, medical practitioners deal with medical causes of behavior, and other staff deal with psychosocial and environmental causes. These limited approaches often involve sitting on the sidelines and letting others struggle with complex issues; for instance, physicians turf an aggression concern to a psychiatric consultant, or a swallowing problem to a speech therapist, or falls to the nursing staff and therapists. There may be minimal symptoms details or little interchange of information beyond the basic symptom. Care plans may be compartmentalized by discipline and only sometimes related to significant causes.
      All the healing professions — including, but not limited to medical practitioners — depend on a foundation of accurate cause identification. The same systematic approach is critical for the entire IDT, even though they will have different roles, knowledge, and skills in the diagnostic process. Each IDT member contributes something (e.g., symptom details, knowledge of the resident’s social or behavior history) to a unified picture that everyone must then use to ultimately help define the issues and their causes before focusing on interventions.

      How Do IDT Members, Including Clinicians, Know Their Limits?

      It is important for all IDT members to consider their limitations and predispositions. An example of cognitive biases and diagnostic errors that have been identified includes overreliance on laboratory tests for diagnosis. As discussed in DeGowin’s Diagnostic Examination, “proper use of the laboratory and imaging are based upon accurate diagnostic hypotheses generated while taking the history and performing the physical examination” — that is, laboratory tests are not a fishing expedition.
      Consider the following real-life example. During their morning report, the nursing staff presented the case of a resident who was afebrile and asymptomatic but had minimal, nonspecific, bilateral basilar infiltrates on a chest x-ray, which had been obtained for vague symptoms. The facility administrator assumed that the patient had pneumonia and directed the nursing staff to have the physician order antibiotics and oxygen. Like many others, this administrator had confused findings with diagnoses.
      Generally, we can identify our limits in cause identification and problem solving in several ways:
      • Self-education (e.g., looking things up) while preparing or attempting to manage a patient’s problems.
      • Hands-on experience with an open mind.
      • Guidance and mentorship from experienced, knowledgeable, and skilled clinicians.
      All IDT members in PALTC should seek and take seriously information or feedback about their cause-identification approaches, but only some do. “Overconfidence bias“ refers to the tendency to have too much faith in one‘s medical decision-making skills, even in difficult cases and situations where patients present with unreliable or nonspecific symptoms (R.L. Trowbridge et al. eds., Teaching Clinical Reasoning, American College of Physicians, 2015).

      Impact of OBRA

      While the Resident Assessment Instrument and related processes within the Omnibus Budget and Reconciliation Act of 1987 (OBRA) regulations have helped improve data collection, its misunderstanding and misuse have often undermined effective cause identification and diagnostic accuracy.
      For example, the screening tools for identifying delirium and depression are only sometimes well understood, used properly, and confirmed adequately. Recent controversies over misdiagnosis of schizophrenia are another of many long-standing examples of insufficient emphasis on critical care processes in the survey process and in clinical practice.

      Back to Basics — Not Magic Bullets

      In short, the issue of “diagnosis” is far more complex, and the challenges of consistently good diagnosis in PALTC are much more formidable, than most of those who work or practice in the setting — or try to improve it — understand and acknowledge. Reliable ways to improve these practices need a lot more attention than they have gotten through the years.
      Good diagnosis is a team sport, which must be played properly. Substantially more medical director engagement in guiding and overseeing diagnostic efforts in nursing homes is needed. Are medical directors prepared to provide it, and are facilities prepared to enable it?
      PALTC has a solid collection of excellent clinicians who are also fine diagnosticians. However, any further meaningful improvement in care quality overall will require substantial attention be paid to improving diagnostic quality. We all need to focus our attention and energy on the basics, and not on magic bullets or more regulatory requirements.
      Dr. Levenson has spent 42 years working as a PALTC physician and medical director in 22 Maryland nursing homes and in helping guide patient care in facilities throughout the country. He has helped lead the drive for improved medical direction and nursing home care nationwide as author of major references in the field and through his work in the educational, quality, and regulatory realms.