Diagnostic Checklists

The goal of these checklists is to prompt physicians to consider a broad differential diagnosis for diagnostically challenging patients in primary care and to help resist the most common cause of missing a diagnosis: the physician's failure to consider it. The lists are not exhaustive, but the goal is feasible because:

1. It is possible to cover 99% of diagnostically challenging complaints with a short list, whereas 100% coverage would require a long list.
2. Similarly, for each complaint it is possible to cover 99% of the diseases that cause it with a short list.
3. Checklists are not needed for complaints that rarely pose diagnostic challenges, either because the list of causes is short (e.g., constipation, rectal bleeding, breast lump, sore throat, nasal congestion), the diagnosis is obvious (e.g., minor trauma, wart), there is a single cause that accounts for the overwhelming majority of cases (e.g., hypertension, obesity), the complaint prompts a standard diagnostic approach which catches important diagnoses even when not initially considered (e.g, rectal bleeding followed by colonoscopy), or the complaint is idiosyncratic (e.g., "funny feeling" in cheek).
4. The checklists do not include diagnoses that are exceedingly rare in North America, diagnoses that are obvious (e.g., major chest trauma as a cause of chest pain), or diagnoses in which the symptom is a late manifestation rather than a presenting complaint (e.g., abnormal uterine bleeding caused by end-stage renal disease).

The diagnoses are listed in approximate order of decreasing prevalence (most common diseases at the top). This ordering is based on limited published data and the authors' experience¹. Users can also sort diagnoses on the basis of "must not miss" and "commonly missed" entries.

Unless otherwise specified, the checklists address complaints by adults rather than children.

These checklists may have five advantages over more traditional differential diagnoses:

1. A shorter list, practical at the point of care
2. An indication of disease prevalence in primary care
3. Identification of "do not miss" diagnoses, designated by an orange corner
4. Identification of diagnoses that are, in fact, commonly missed (designated by a purple corner and partly based on Schiff et al., 2009².
5. Lumping and splitting to meet the needs of clinicians rather than pathologists or billers (e.g., better to split "myocardial infarction" from "heart disease," but better to lump "abnormal uterine bleeding" rather than splitting into "dysfunctional uterine bleeding" vs. "structural causes" because this distinction may not be initially apparent).

The lists have been be adapted for the web.

References

1. Cherry DK, et al. National Ambulatory Medical Care Survey: 2006 Summary. National Health Statistics Reports. Number 3. August 6, 2008.
2. Schiff GD, et al. Diagnostic error in medicine: analysis of 583 physician-reported errors. Arch Intern Med. 2009;169:1881-7; and on Zwaan L, et al. Patient record review of the incidence, consequences, and causes of diagnostic adverse events. Arch Intern Med. 2010 Jun 28;170(12):1015-21).
3. Ely, J. W., M. Graber, P Croskerry (2011). Checklists to reduce diagnostic errors. Academic Medicine 86(3): 7.
4. Graber, M. L. (2009). Educational strategies to reduce diagnostic error: can you teach this stuff? Adv Health Sci Educ Theory Pract 14 Suppl 1: 63-69.
5. Berner, E. and M. Graber (2008). Overconfidence as a cause of diagnostic error in medicine. Am J Med 121(5 Suppl): S2-23.