Research ArticleTheory

Solving the Diagnostic Challenge: A Patient-Centered Approach

Norbert Donner-Banzhoff
The Annals of Family Medicine July 2018, 16 (4) 353-358; DOI: https://doi.org/10.1370/afm.2264

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    The threshold model of the diagnostic process.

    Note: The figure depicts 2 examples of diagnostic decision making. The shaded area represents the state of diagnostic uncertainty. The top example shows eventual crossing of the upper boundary (therapeutic threshold), indicating ruling in of disease and start of treatment or other intervention. The bottom example shows eventual crossing of the lower boundary (diagnostic threshold), indicating ruling out of disease.

  • Figure 2
    Figure 2

    Problem space of the diagnostic task.

    Note: A problem space in which the outstanding geometric forms denote unusual and relevant findings (symptoms), typically identified by inductive foraging with patient input. Arrow points to a shaded limited problem area to be explored by a triggered routine.

  • Figure 3
    Figure 3

    Cognitive strategies and related tactics used in the diagnostic task.

Tables

  • Table 1

    Key Messages on the Diagnostic Process in Primary Care

    • In generalist settings, the problem space of possible problems (diagnoses) is almost infinite.
    • Recent research suggests that established descriptions and models do not adequately capture what clinicians do to arrive at a diagnosis.
    • Searching the problem space by inductive foraging and triggered routines is emerging as a diagnostic strategy that can be adapted to the generalist setting.
    • The patient has a leading role in this collaborative process.

Additional Files

  • The Article in Brief

    Solving the Diagnostic Challenge: A Patient-Centered Approach

    Norbert Donner-Banzhoff

    Background According to family physician Norbert Donner-Banzhoff, building an effective relationship with a patient and making a diagnosis are not separate skills. Rather, diagnosing a patient efficiently and effectively is a process best shared by patient and physician.

    What This Study Found Donner-Banzhoff introduces the concept of inductive foraging, which begins with inviting patients to describe the problem that brings them to the doctor. "If they are allowed to do this without interference," he writes, "they will lead their clinician to symptoms and problems as they perceive them," often mentioning additional symptoms, associations, and potential explanations or concerns. This is particularly important in primary care, because the problem space, i.e., the universe of potential diagnoses, is vast and the probability of specific diagnoses is small. After the patient has helped define the problem space, physicians can gain additional information by direct questions, however Donner-Banzhoff cautions against testing hypotheses too early, because important information might be missed. This process depends on the quality of the clinician-patient relationship and requires sufficient time and encouragement for the patient to mention all concerns. The result, he states, is a synergistic and ultimately time-saving process of shared enquiry.

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