The information-gathering approaches can be employed at different times, and diagnostic information can be obtained in different orders. Performing a clinical history and interview, conducting a physical exam, performing diagnostic testing, and referring or consulting with other clinicians are all ways of accumulating information that may be relevant to understanding a patient’s health problem. Once a patient seeks health care, there is an iterative process of information gathering, information integration and interpretation, and determining a working diagnosis. The patient is likely the first person to consider his or her symptoms and may choose at this point to engage with the health care system.
The diagnostic process proceeds as follows: First, a patient experiences a health problem. The committee’s depiction of the diagnostic process draws on an adaptation of a decision-making model that describes the cyclical process of information gathering, information integration and interpretation, and forming a working diagnosis (Parasuraman et al., 2000 Sarter, 2014). This process occurs over time, within the context of a larger health care work system that influences the diagnostic process (see Box 2-1). The committee concluded that the diagnostic process is a complex, patient-centered, collaborative activity that involves information gathering and clinical reasoning with the goal of determining a patient’s health problem. To help frame and organize its work, the committee developed a conceptual model to illustrate the diagnostic process (see Figure 2-1). To help manage this complexity, the chapter concludes with a discussion of the role of clinical practice guidelines in informing decision making in the diagnostic process. The rising complexity of health care and the sheer volume of advances, coupled with clinician time constraints and cognitive limitations, have outstripped human capacity to apply this new knowledge.
It also highlights the mounting complexity of health care, due to the ever-increasing options for diagnostic testing 2 and treatment, the rapidly rising levels of biomedical and clinical evidence to inform clinical practice, and the frequent comorbidities among patients due to the aging of the popula-ġ In this report, the committee employs the terminology “the diagnostic process” to convey diagnosis as a process.Ģ The committee uses the term “diagnostic testing” to be inclusive of all types of testing, including medical imaging, anatomic pathology, and laboratory medicine, as well as other types of testing, such as mental health assessments, vision and hearing testing, and neurocognitive testing. The chapter describes important considerations in the diagnostic process, such as the roles of diagnostic uncertainty and time. In addition, public policy decisions are often influenced by diagnostic information, such as setting payment policies, resource allocation decisions, and research priorities (Jutel, 2009 Rosenberg, 2002 WHO, 2012).
1 When a diagnosis is accurate and made in a timely manner, a patient has the best opportunity for a positive health outcome because clinical decision making will be tailored to a correct understanding of the patient’s health problem (Holmboe and Durning, 2014). Diagnosis has been described as both a process and a classification scheme, or a “pre-existing set of categories agreed upon by the medical profession to designate a specific condition” (Jutel, 2009). Diagnosis has important implications for patient care, research, and policy. This chapter provides an overview of diagnosis in health care, including the committee’s conceptual model of the diagnostic process and a review of clinical reasoning.
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