Ten Principles for More Conservative, Care-Full Diagnosis
Authors: Gordon D. Schiff, Stephen A. Martin, David H. Eidelman, Lynn A. Volk, Elise Ruan, Christine Cassel, William Galanter, Mark Johnson, Annemarie Jutel, Kurt Kroenke, Bruce L. Lambert, Joel Lexchin, Sara Myers, Alexa Miller, Stuart Mushlin, Lisa Sanders, Aziz Sheikh
Journal: Annals of Internal Medicine (2018)

Ideas and Opinions6 November 2018Ten Principles for More Conservative, Care-Full DiagnosisFREEGordon D. Schiff, MD, Stephen A. Martin, MD, EdM, David H. Eidelman, MD, Lynn A. Volk, MHS, Elise Ruan, BS, Christine Cassel, MD, William Galanter, MD, Mark Johnson, MD, MS, Annemarie Jutel, PhD, Kurt Kroenke, MD, Bruce L. Lambert, PhD, Joel Lexchin, MSc, MD, Sara Myers, BA, Alexa Miller, MA, Stuart Mushlin, MD, Lisa Sanders, MD, and Aziz Sheikh, MDGordon D. Schiff, MDBrigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (G.D.S., M.J.), Stephen A. Martin, MD, EdMUniversity of Massachusetts Medical School, Worcester, Massachusetts (S.A.M.), David H. Eidelman, MDMcGill University, Montreal, Quebec, Canada (D.H.E.), Lynn A. Volk, MHSBrigham and Women's Hospital, Boston, Massachusetts, and Partners HealthCare, Somerville, Massachusetts (L.A.V., S.M.), Elise Ruan, BSBrigham and Women's Hospital and Tufts University School of Medicine, Boston, Massachusetts, and Partners HealthCare, Somerville, Massachusetts (E.R.), Christine Cassel, MDKaiser Permanente School of Medicine, Pasadena, California (C.C.), William Galanter, MDUniversity of Illinois, Chicago, Chicago, Illinois (W.G.), Mark Johnson, MD, MSBrigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (G.D.S., M.J.), Annemarie Jutel, PhDHarvard Medical School, Boston, Massachusetts; Victoria University of Wellington, Wellington, New Zealand (A.J.), Kurt Kroenke, MDIndiana University, Indianapolis, Indiana (K.K.), Bruce L. Lambert, PhDNorthwestern University, Chicago, Illinois (B.L.L.), Joel Lexchin, MSc, MDYork University, Toronto, Ontario, Canada (J.L.), Sara Myers, BABrigham and Women's Hospital, Boston, Massachusetts, and Partners HealthCare, Somerville, Massachusetts (L.A.V., S.M.), Alexa Miller, MAArtsPractica, Guilford, Connecticut (A.M.), Stuart Mushlin, MDBrigham Circle Medical Associates, Boston, Massachusetts (S.M.), Lisa Sanders, MDYale University School of Medicine, New Haven, Connecticut (L.S.), and Aziz Sheikh, MDThe University of Edinburgh, Edinburgh, United Kingdom (A.S.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M18-1468 Annals Author Insight Video - Gordon D. Schiff, MD In this video, Gordon D. Schiff, MD, offers additional insight into the article, "Ten Principles for More Conservative, Careful Diagnosis." SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Many spotlights currently illuminate the challenges associated with medical diagnosis. The National Academy of Medicine estimates that all patients will experience 1 serious diagnostic error during their lifetime, and diagnostic errors are now the leading cause of medical malpractice claims (1, 2). To avoid missing diagnoses, clinicians often order imaging and/or laboratory studies and initiate specialist referrals. However, physicians and patients are also urged to use fewer tests; nearly every U.S. medical specialty and 20 countries worldwide have initiated Choosing Wisely campaigns (3). Evidence increasingly shows that indiscriminate diagnostic testing and referrals often fail to provide definitive explanations or improve outcomes and at times are more harmful than beneficial.Balancing underdiagnosis (missing or delaying important diagnoses) and wasteful, harmful overdiagnosis (labeling patients with diseases that may never cause suffering or death) is often portrayed as the need "to keep the pendulum from swinging too far in either direction" (4). Rather than framing the problem as a simple, linear tradeoff, we believe it must be more fundamentally conceptualized as 2 sides of the same coin unified by the need for more cautious and careful approaches.We assembled a diverse group of clinicians, educators, and health policy and communication experts to create recommendations to support improved approaches to clinical care and health policy (www.patientsafetyresearch.org/Schiff_Ten_Principles_Conservative_Diagnosis.pdf). Building on our previous conservative principles of medication prescribing (5), we developed 10 overarching principles based on core attributes of care (good communication, trusting relationships, and continuity of care) and key patient safety lessons (awareness of pitfalls, safety nets to mitigate harm, and a culture that facilitates learning/avoiding blame) that go beyond current test-by-test recommendations.Promoting Enhanced Caring and ListeningPatients come to clinicians seeking explanations for their symptoms. Clinicians often rely on laboratory and imaging studies and specialist referrals to rule out serious diagnoses and identify patients who could benefit from particular treatments. However, this approach rests on the questionable assumptions that testing is key to making an accurate diagnosis, an exact diagnosis is always available and needed to select therapies, and ordering tests best shows that clinicians are taking patients' concerns seriously.Medicine currently shortchanges the patient history and physical examination, even though carefully listening to and observing patients over time often provide more valuable information than multiple radiologic or chemical tests. We must stop equating testing with caring and thoroughness and instead emphasize respectful listening, examination, follow-up, and collaboration with the patient to "coproduce" diagnoses (1, 6).Developing a New Science of UncertaintyAs precision medicine becomes a major preoccupation, appreciation of the pervasiveness of uncertainty in medicine has paradoxically increased (7). We need to develop a new science and praxis of diagnostic uncertainty that acknowledges complex biological and social systems and serves as a starting point for more modest, reflective, and conservative practice. Doing so requires acknowledging widespread uncertainty, better operationalizing follow-up, and communicating honestly about uncertainty.Rethinking SymptomsUp to one half of symptoms defy definitive medical diagnosis. Further, many symptoms are self-limiting: 75% to 80% of symptoms improve over 4 to 12 weeks, usually regardless of medical intervention (8). Some patients meet criteria for depression, anxiety, or somatoform illnesses, yet these diagnoses are overlooked in two thirds of patients. Visits for "medically unexplained symptoms" currently represent the fastest-growing type of medical encounter. Caring for these patients can be frustrating, leading clinicians to be dismissive or stigmatizing. We need to move away from exhaustively trying to rule out multiple rare diseases and then labeling patients' symptoms as nonorganic, toward more helpful and supportive approaches.Maximizing Continuity and TrustContinuity is the foundation of judicious clinical practice. Without knowledgeable, trusting relationships, clinicians must often resort to defensive, inadequately informed, and costly styles of practice. Health systems that maximize relational and informational continuity perform better and cost less (9), and patients value having clinicians who know them well. Financial incentives can undermine long-term, trusting relationships. If clinicians are incentivized to withhold tests, patients may find trusting "watch-and-wait" recommendations difficult (3).Taming and Taking TimeTime is the currency of clinical care. Although few clinicians would disagree in principle with the conservative diagnosis practices that we advocate, many argue that they simply do not have time for prolonged discussions about uncertainty, exploration of symptoms in greater detail, or comprehensive follow-up. Time is a powerful incubator for diagnosis. Conservative diagnosis requires carefully and skillfully weighing information as it evolves. Having adequate time to listen, observe, discuss, and reflect is a decisive factor that separates good diagnosis from under- and overdiagnosis. Practical strategies include redesigning care to optimize the roles of other team members and reengineering electronic health records and follow-up systems to support watchful waiting, a fundamental pillar of conservative diagnosis and an antidote to the unwatchful neglect that patients fear (10).Linking Diagnosis to TreatmentDiagnosis needs to stand less alone and more arm in arm with treatment. The value of diagnosis is greater in conditions with effective, specific, or urgent treatments and more limited if no therapy is available, a diagnosis is not needed to select among treatment options, and/or treatment can be safely deferred. Diagnosing conditions for which patients have no interest in being treated (for example, chemotherapy and surgery) may be unwarranted and disrespectful.Ordering and Interpreting Tests More ThoughtfullyConservative diagnosis is not just saying "no" to tests or the patients requesting them. Rather, it is about more intelligently selecting, timing, sequencing, interpreting, and weighing the marginal benefits of tests. Few appreciate the biases and lack of rigor involved in evaluating new diagnostic tests, which are not subject to the same evidence and regulatory standards as medications. We also often do not fully consider the potential harms of testing (Table).Table. Potential Harms From Diagnostic Testing*Safety Nets: Incorporating Lessons From Diagnostic ErrorsRecent attention given to diagnostic errors might seem to argue for more aggressive defensive medicine to rule out myriad diagnoses lest they be missed and labeled as errors and delays. However, additional testing does not necessarily result in answers that patients and clinicians seek. Being aware of potential diagnostic errors can help avoid pitfalls and build safety nets and systems to protect against known errors.Addressing Cancer: Fears and ChallengesPatients understandably fear missed cases of cancer. Almost any symptom can be due to cancer. Clinicians and the media have long promoted early diagnosis, but serious controversies surround efforts to screen for and diagnose most types of cancer. These issues are complex. Furthermore, data are often inconclusive or conflicting, particularly considering such issues as lead-time bias; overdiagnosis of cancer that is incidentally discovered but best left untreated; false-positive and false-negative test results; uncertainties about the value of treatment; and questions about the marginal benefit of early treatment. We need to help patients understand the toll imposed by false-positive results and overdiagnosed cancer to appreciate the need to strike a balance between treating the few with harmful cancer and avoiding harm to the many without it.Diagnostic Stewardship: Transforming the Role of Specialists and Emergency Department CliniciansImplicit in conservative diagnosis is minimizing indiscriminate use of specialty referrals and emergency departments. However, both specialists and emergency department clinicians can positively contribute by leveraging their knowledge and playing stewardship roles. Specialists can provide guidance when testing or referring is not needed and offer safety nets (such as triage electronic consultations/second opinions and guidelines) to conservatively assess and reassure patients. Emergency department clinicians can work with primary care clinicians to help reduce unnecessary emergency department visits while helping to expedite truly urgent evaluations.ConclusionAchieving more judicious diagnosis mandates policy support to redesign care at both the individual patient and system levels. Practical safety nets can protect the safety and quality of diagnosis and promote more conservative practice (www.patientsafetyresearch.org/Schiff_Ten_Principles_Conservative_Diagnosis.pdf).References1. Balogh E, Miller BT, Ball J, eds. Improving Diagnosis in Health Care. Washington, DC: National Academies Pr; 2015. Google Scholar2. Schiff GD, Puopolo AL, Huben-Kearney A, Yu W, Keohane C, McDonough P, et al. Primary care closed claims experience of Massachusetts malpractice insurers. JAMA Intern Med. 2013;173:2063-8. [PMID: 24081145] doi:10.1001/jamainternmed.2013.11070 CrossrefMedlineGoogle Scholar3. Levinson W, Kallewaard M, Bhatia RS, Wolfson D, Shortt S, Kerr EA; Choosing Wisely International Working Group. "Choosing Wisely": a growing international campaign. BMJ Qual Saf. 2015;24:167-74. [PMID: 25552584] doi:10.1136/bmjqs-2014-003821 CrossrefMedlineGoogle Scholar4. Landro L. A medical detective story: why doctors make diagnostic errors. The Wall Street Journal. 26 September 2015 Accessed at www.wsj.com/articles/a-medical-detective-story-why-doctors-make-diagnostic-errors-1443295859 on 7 September 2018. Google Scholar5. Schiff GD, Galanter WL, Duhig J, Lodolce AE, Koronkowski MJ, Lambert BL. Principles of conservative prescribing. Arch Intern Med. 2011;171:1433-40. [PMID: 21670331] doi:10.1001/archinternmed.2011.256 CrossrefMedlineGoogle Scholar6. Hart JT. Clinical and economic consequences of patients as producers. J Public Health Med. 1995;17:383-6. [PMID: 8639335] MedlineGoogle Scholar7. Simpkin AL, Schwartzstein RM. Tolerating uncertainty—the next medical revolution? N Engl J Med. 2016;375:1713-5. [PMID: 27806221] CrossrefMedlineGoogle Scholar8. Kroenke K. A practical and evidence-based approach to common symptoms: a narrative review. Ann Intern Med. 2014;161:579-86. [PMID: 25329205]. doi:10.7326/M14-0461 LinkGoogle Scholar9. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457-502. [PMID: 16202000] CrossrefMedlineGoogle Scholar10. Schiff GD. Minimizing diagnostic error: the importance of follow-up and feedback. Am J Med. 2008;121:S38-42. [PMID: 18440354] doi:10.1016/j.amjmed.2008.02.004 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Gordon Schiff, Kurt Kroenke, Bruce Lambert, Lisa Sanders, Aziz SheikhHarvard, Indiana University, Northwestern University, Yale, University of Edinburgh5 February 2019 Response We are grateful for these comments highlighting different but important aspects of the relevance of our "Ten Principles for More Conservative, Care-Full Diagnosis" (full version is available at http://www.patientsafetyresearch.org/Schiff_Ten_Principles_Conservative_Diagnosis.pdf).Rediger and Miles describe key intersections between the high prevalence of trauma (childhood, adult), and clinic/office visits for physical symptoms that lack a clear medical diagnosis. We agree and suggest that diagnostic challenges in caring for this important group of patients perfectly illustrate the point we make in our introduction to the 10 principles – that under- and over-diagnosis are not opposite, competing pitfalls to avoid. Instead, they are two sides of the same coin that must be understood and approached holistically rather than trade off one at the expense of the other. Patients, particularly female patients, have experienced centuries of misdiagnosis when they presented with physical symptoms that were dismissed as "psychological," "hypochondriacal," "nonorganic," or even "hysterical"(1). At the same time, patients with serious prior or ongoing trauma are often not diagnosed and referred for the help they need, but instead are subjected to needless imaging, labs, and stigma (when the tests return normal) (2). Overcoming this requires, as we elaborate in the 10 Principles, an approach that emphasizes better listening, continuity, trusting relationships, appreciation of test limitations, and, yes…. time.Pelaccia, however, warns that "more time to diagnose may not be a good idea." He cites findings from case vignettes given to medical trainees. In the real world, there are two types of time: cross-sectional (within a single visit) and longitudinal (across several visits). Within a visit, a careful history is adequate for 75% of the diagnoses for patients presenting with symptoms (3). There is clearly a threshold below which clinicians lack sufficient time to take an adequate history, reflect, discuss with the patient and meaningfully document their thinking. Many clinicians would argue they are bumping up against this lower limit of minimum time. Across visits, follow-up has been found to sort out the majority of symptoms that resolve in 2-12 weeks (3). By "time is an incubator" we meant both types of time and emphasized the importance of "follow-up systems to support watchful waiting." Even Sherbino (who Pelaccia cites) acknowledges that "with routine cases rapid processing is both efficient and effective. However, when cases are more demanding, there may be value in more deliberative thinking" (4).Finally, we thank Meisel for endorsement of our 10 Principles.Gordon Schiff - Brigham and Women's Hospital, Harvard Medical School Center for Primary Care Kurt Kroenke - Regenstrief Institute, Indiana University School of MedicineBruce Lambert - Center for Communication and Health, Northwestern University Lisa Sanders – Yale Medical School Aziz Sheikh Usher Institute of Population Health, University of Edinburgh1. Tasca C, Rapetti M, Carta MG, Fadda B. Women and hysteria in the history of mental health. Clin Pract Epidemiol Ment Health. 2012;8:110-9. Epub 2012/11/02. doi: 10.2174/1745017901208010110. PubMed PMID: 23115576; PubMed Central PMCID: PMCPMC3480686.2. Murray AM, Toussaint A, Althaus A, Lowe B. The challenge of diagnosing non-specific, functional, and somatoform disorders: A systematic review of barriers to diagnosis in primary care. J Psychosom Res. 2016;80:1-10. Epub 2016/01/02. doi: 10.1016/j.jpsychores.2015.11.002. PubMed PMID: 26721541.3. Kroenke K. A practical and evidence-based approach to common symptoms: a narrative review. Ann Intern Med. 2014;161(8):579-86. Epub 2014/10/21. doi: 10.7326/M14-0461. PubMed PMID: 25329205.4. Sherbino J, Dore KL, Wood TJ, Young ME, Gaissmaier W, Kreuger S, et al. The relationship between response time and diagnostic accuracy. Acad Med. 2012;87(6):785-91. Epub 2012/04/27. doi: 10.1097/ACM.0b013e318253acbd. PubMed PMID: 22534592. James L. Meisel, MD, MHPE, FACPAssociate Professor, Boston University School of Medicine19 November 2018 Care-Full Diagnosis: Springboard to What Really Matters "Ten Principles for More Conservative, Care-Full Diagnosis" is much more than a perspective piece. As intended, its authors incorporate not just principles of decreasing diagnostic harm but highlight the dearth of time to accomplish what matters to patients and caregivers; the need for clinical reasoning to precede diagnostic testing; and the central roles of continuity, humility, and trust in the doctor-patient relationship. I offer that the article should be considered a landmark publication, to be actively taught and broadly reflected upon within undergraduate and graduate medical education. Thierry Pelaccia, MD, MEd, PhDCentre for Training and Research in Health Sciences Education (CFRPS), Faculty of Medicine, University of Strasbourg, France12 November 2018 Taking more time to diagnose may not be a good idea... despite its apparent obviousness! The article published by Schiff and colleagues in the category "Ideas and Views" deals with a crucial subject (1). As the authors point out, diagnostic errors are frequent and constitute a major public health and quality of care issue. Recently, Makay & Daniel pointed out that medical error -the most frequent of which is diagnostic error- is the third leading cause of death in the United States (2). The article by Schiff and colleagues provides many avenues for reflection that deserve to be taken into consideration by physicians and that require additional research.Schiff and colleagues write in particular that "Time is a powerful incubator for diagnosis" and that "Having adequate time to listen, observe, discuss, and reflect is a decisive factor that separates good diagnosis from under- and overdiagnosis" (1). We believe that this statement should be considered with caution. The notion that taking more time allows for a better diagnosis is part of the "debiaising" strategies (3). The authors' advice on the importance of "Being aware of potential diagnostic error" is part of the same strategies. Debiaising strategies have recently been criticized in a literature review (4). In particular, several studies have shown that taking more time to diagnose does not increase diagnostic performance and may even reduce it (5,6). Other studies have shown opposite or contradictory results, with differences depending on the degree of complexity of the case and the clinicians' level of experience. They have been criticized for the protocol used, which has sometimes been developed to generate biases resulting from the way the case was initially presented to subjects or the way in which subjects were trained (6). In their review, Norman et al. concluded that "strategies focused on the reorganization of knowledge to reduce errors" are the only ones with "small but consistent benefits" (4).It therefore seems important to us not to consider that debiaising strategies, several of which are described in the article by Schiff and colleagues, will systematically be associated with an improvement in the quality of the diagnostic process and performance. In addition to the recommendations by Schiff and colleagues, it should be stressed that training has an important role to play in improving diagnostic performance, as it determines how students' knowledge will organize in long-term memory. It could also be a determining factor in transforming the physician's relationship to uncertainty, as part of the development of a "New science of uncertainty", as suggested by the authors (1). The challenge is to reduce physicians' intolerance to uncertainty, an important factor in overprescribing diagnostic tests. 1. Schiff GD, Martin SA, Eidelman DH, Volk LA, Ruan E, Cassel C, et al. Ten Principles for More Conservative, Care-Full Diagnosis. Ann Intern Med. 2018 Nov 6;169(9):643-646. 2. Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016 May;353:i2139. 3. Croskerry P. When I say… cognitive debiasing. Med Educ. 2015 Jul;49(7):656–7. 4. Norman GR, Monteiro SD, Sherbino J, Ilgen JS, Schmidt HG, Mamede S. The Causes of errors in clinical reasoning: Cognitive biases, knowledge deficits, and dual process thinking. Acad Med. 2017 Jan;92(1):23–30. 5. Ilgen JS, Bowen JL, McIntyre LA, Banh KV, Barnes D, Coates WC, et al. Comparing diagnostic performance and the utility of clinical vignette-based assessment under testing conditions designed to encourage either automatic or analytic thought. Acad Med. 2013 Oct;88(10):1545–51. 6. Sherbino J, Dore KL, Wood TJ, Young ME, Gaissmaier W, Kreuger S, et al. The relationship between response time and diagnostic accuracy. Acad Med. 2012 Jun;87(6):785–91. Katherine Rediger, CRNP, D.R. Bailey Miles, MDJohns Hopkins Community Physicians25 October 2018 The 10 Principles and Trauma Informed Care We were pleased to read Dr. Schiff and colleagues' the "Ten Principles of a More Conservative Care-Full Diagnosis" and encourage medical providers to adopt this approach widely (1). We feel the principles are particularly applicable to trauma informed care.Adverse childhood experiences (ACEs) and adult trauma are prevalent but often not acknowledged within the medical context. Patients who have experienced traumatic events often feel a loss of control over their bodies, their relationships, and their lives. Their traumatic experiences, including ACEs and adult trauma, may manifest as physical symptoms as well as increased health care use and costs (2). This association is consistent with our experience working with an urban Medicaid population with a high prevalence of ACEs and adult trauma. As the authors note, at least a third of common symptoms that prompt medical visits will not have a clear-cut medical diagnosis (3). Somatization after trauma is not fully understood, but negative affectivity and feelings of incompetence are associated with somatoform symptoms (4). Furthermore, pain is often exacerbated by the patient's anxiety and distress, leading to further disability.Patients and providers alike often have little understanding of the link between trauma and physical symptoms and may continue to seek an explanation and treatment for the problem. In many cases, patients may undergo considerable medical testing without any abnormal findings or with incidental findings, which in some cases can be "hypothesis generating" (5) and lead to unnecessary diagnostics and intervention. Unfortunately, negative findings on diagnostic testing have not been found to be reassuring for most patients (5). As Dr. Schiff and colleagues note, our profession often fails to consider the harm that may arise from testing (1). Using an approach such as the one outlined in "Ten Principles" allows a traumatized patient to participate in medical decision-making, which can empower the patient and promote healing. Continuity of care is also a critical component of building a relationship with a traumatized patient by creating trust, allowing the patient to feel safe, and building on knowledge of the individual's patterns and coping abilities.The public health burden of untreated trauma is enormous and costs the health care system billions of dollars in unnecessary medical tests and procedures. Many of those dollars would be better spent on integrating behavioral health services into primary care and acknowledging the deep connection between physical symptoms and trauma.References1. Schiff GD, Martin SA, Eidelman DH, Volk LA, Ruan E, Cassel C, et al. Ten Principles for More Conservative, Care-Full Diagnosis. Ann Intern Med [Internet]. 2018 Oct 2 [cited 2018 Oct 24]; Available from: http://annals.org/article.aspx?doi=10.7326/M18-14682. Katon W. Medical Symptoms without Identified Pathology: Relationship to Psychiatric Disorders, Childhood and Adult Trauma, and Personality Traits. Ann Intern Med. 2001 May 1;134(9_Part_2):917. 3. Kroenke K. A Practical and Evidence-Based Approach to Common Symptoms: A Narrative Review. Ann Intern Med. 2014 Oct 21;161(8):579. 4. Elklit A, Christiansen DM. Predictive factors for somatization in a trauma sample. Clin Pract Epidemiol Ment Health. 2009 Jan 6;5(1):1. 5. Page LA, Wessely S. Medically Unexplained Symptoms: Exacerbating Factors in the Doctor-Patient Encounter. J R Soc Med. 2003;96:223–7. Author, Article, and Disclosure InformationAffiliations: Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (G.D.S., M.J.)University of Massachusetts Medical School, Worcester, Massachusetts (S.A.M.)McGill University, Montreal, Quebec, Canada (D.H.E.)Brigham and Women's Hospital, Boston, Massachusetts, and Partners HealthCare, Somerville, Massachusetts (L.A.V., S.M.)Brigham and Women's Hospital and Tufts University School of Medicine, Boston, Massachusetts, and Partners HealthCare, Somerville, Massachusetts (E.R.)Kaiser Permanente School of Medicine, Pasadena, California (C.C.)University of Illinois, Chicago, Chicago, Illinois (W.G.)Harvard Medical School, Boston, Massachusetts; Victoria University of Wellington, Wellington, New Zealand (A.J.)Indiana University, Indianapolis, Indiana (K.K.)Northwestern University, Chicago, Illinois (B.L.L.)York University, Toronto, Ontario, Canada (J.L.)ArtsPractica, Guilford, Connecticut (A.M.)Brigham Circle Medical Associates, Boston, Massachusetts (S.M.)Yale University School of Medicine, New Haven, Connecticut (L.S.)The University of Edinburgh, Edinburgh, United Kingdom (A.S.)Note: Drs. Martin, Eidelman, Cassel, Galanter, Johnson, Jutel, Kroenke, Lambert, Lexchin, Mushlin, Sanders, and Sheikh and Ms. Myers are members of an expert panel assembled for collaborative development of conservative diagnosis principles.Disclaimer: The funding source had no role in the design or conduct of the study; collection, analysis, or interpretation of the data; or preparation or review of the manuscript. The findings and conclusions in this commentary are those of the authors and do not necessarily represent the official position of the Gordon and Betty Moore Foundation.Acknowledgment: The authors thank Ami Karlage for editorial support and Andrea Lim for manuscript support.Grant Support: From the Gordon and Betty Moore Foundation.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-1468.Corresponding Author: Gordon D. Schiff, MD, Brigham and Women's Hospital, 1620 Tremont Street, 3rd Floor, Room 03-02-2N, Boston, MA 02120; e-mail, [email protected]org.Current Author Addresses: Dr. Schiff: Brigham and Women's Hospital, 1620 Tremont Street, 3rd Floor, Room 03-02-2N, Boston, MA 02120.Dr. Martin: Barre Family Health Center, 151 Worcester Road, Barre, MA 01005.Dr. Eidelman: McGill University, 3605 Rue de la Montagne, Montreal, Quebec H3G 2M1, Canada.Ms. Volk: Partners HealthCare, 399 Revolution Drive, Somerville, MA 02145.Ms. Ruan: Tufts University, 2 Hawthorne Place, Boston, MA 02114.Dr. Cassel: 64 Lodge Trail, Santa Fe, NM 87506.Dr. Galanter: Section of Academic Internal Medicine, 840 S. Wood, 440D, Chicago, IL 60612. Dr. Johnson: Department of Medicine, Mount Auburn Hospital, 330 Mount Auburn Street, Cambridge, MA 02138.Prof. Jutel: Victoria University of Wellington, PO Box 600, Kelburn, Wellington 6140, New Zealand.Dr. Kroenke: Regenstrief Institute, 1101 West 10th Street, RF 221, Indianapolis, IN 46202.Dr. Lambert: Northwestern University, 710 N. Lake Shore Drive, 15th Floor, Chicago, IL 60611.Dr. Lexchin: York University, 4700 Keele Street, Toronto, Ontario M3J 1P3, Canada.Ms. Myers: 2783 Lancashire Road, Apartment 10, Cleveland, OH 44106.Ms. Miller: 201 Dromara Road, Guilford, CT 06437.Dr. Mushlin: Brigham Circle Medical Associates, 75 Francis Street, Boston, MA 02115.Dr. Sanders: St. Raphael's Hospital, 1450 Chapel Street, Room M423E, New Haven, CT 06511.Dr. Sheikh: Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, United Kingdom.Author Contributions: Conception and design: G.D. Schiff, S.A. Martin, D.H. Eidelman, L.A. Volk, E. Ruan, S. Myers.Drafting of the article: G.D. Schiff, S.A. Martin, D.H. Eidelman, L.A. Volk, E. Ruan, C. Cassel, W. Galanter, M. Johnson, A. Jutel, K. Kroenke, B.L. Lambert, J. Lexchin, S. Myers, A. Miller, S. Mushlin, L. Sanders, A. Sheikh.Critical revision of the article for important intellectual content: G.D. Schiff, S.A. Martin, D.H. Eidelman, L.A. Volk, E. Ruan, C. Cassel, W. Galanter, M. Johnson, A. Jutel, K. Kroenke, B.L. Lambert, J. Lexchin, S. Myers, A. Miller, S. Mushlin, L. Sanders, A. Sheikh.Final approval of the article: G.D. Schiff, S.A. Martin, D.H. Eidelman, L.A. Volk, E. Ruan, C. Cassel, W. Galanter, M. Johnson, A. Jutel, K. Kroenke, B.L. Lambert, J. Lexchin, S. Myers, A. Miller, S. Mushlin, L. Sanders, A. Sheikh.Obtaining of funding: G.D. Schiff, L.A. Volk.Administrative, technical, or logistic support: L.A. Volk, E. Ruan, S. Myers.This article was published at Annals.org on 2 October 2018. PreviousarticleNextarticle Advertisement Annals Author Insight Video - Gordon D. Schiff, MD In this video, Gordon D. Schiff, MD, offers additional insight into the article, "Ten Principles for More Conservative, Careful Diagnosis." FiguresReferencesRelatedDetailsSee AlsoTen Principles for More Conservative, Care-Full Diagnosis Katherine Rediger and Bailey Miles Ten Principles for More Conservative, Care-Full Diagnosis Thierry Pelaccia Ten Principles for More Conservative, Care-Full Diagnosis James L. Meisel Ten Principles for More Conservative, Care-Full Diagnosis Gordon D. Schiff , Kurt Kroenke , Bruce L. 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Meisel, MD, MHPEA manifesto for the future of laboratory medicine professionals 6 November 2018Volume 169, Issue 9Page: 643-645KeywordsCancer treatmentCommunication in health careEmergency departmentHealth information technologyHospital medicineInterleukinsPatientsPrecision medicineResearch laboratoriesSafety ePublished: 2 October 2018 Issue Published: 6 November 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...