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Unexplained complaints in primary care: evidence of action bias: when patients present with symptoms that do not fit a recognizable diagnostic pattern, testing--although often unnecessary--is preferred by primary care physicians.

ABSTRACT

Purpose * Primary care physicians sometimes encounter patients with clinical complaints that do not fit into a recognized diagnostic pattern. This study was undertaken to assess the way physicians respond to patients whose symptoms are unusual or unexplained--that is, what approach they take in the absence of a working hypothesis.

Methods * We surveyed 130 primary care physicians affiliated with 3 academic centers in Israel, presenting 5 clinical vignettes describing patients who had unusual complaints, no clear diagnosis, and no apparent need for urgent care. We asked physicians to provide the most likely diagnosis for each case and to rate their level of confidence in that diagnosis; respondents were also asked to provide a management strategy for each case and their level of confidence in the chosen approach. Finally, we asked the physicians to estimate how many of their own patients have presentations similar to the individuals in the clinical vignettes.

Results * Physicians proposed, on average, 22 diagnoses for each case. Most indicated that they would choose action (testing, consulting, sending the patient to the emergency department, or prescribing) rather than follow-up only (87% vs 13%; P<.01).

Respondents' confidence in the management approach they had chosen for all the cases was higher than their confidence in the diagnoses (5.6 vs 4.3, respectively, on a scale of 1-10; P<.O01). Physicians estimated that 10% to 20% of the patients they see in their practice have unusual or unexplained symptoms that are difficult to diagnose.

Conclusion * Uncertain diagnosis is a regular challenge for primary care physicians. In such cases, we found that physicians prefer a workup to follow-up, an inclination consistent with "action bias."

**********

Physicians in primary care sometimes encounter patients with clinical complaints that do not fit into a recognized diagnostic pattern. (1) There are varying reports of the prevalence of such cases, ranging from [less than or equal to] 10% when stringent definitions of medically unexplained symptoms are used (2) to as high as 40% to 60% of visits. (3,4) Unexplained complaints, which may or may not be related to psychiatric disorders, can significantly contribute to high consumption of health care resources, (5) Uncertain diagnoses are associated with increased testing (6) and false-positive results, which often lead to more tests and complications. (7)

When physicians face medically unexplained symptoms, their behavior often differs from the watchful waiting approach some recommend. (6) This behavior has been attributed to various factors, such as fear of litigation, greater concern about omission than commission, and perception of patient expectations. (5)

A study involving young patients suggested bias toward intervention for common pediatric diagnoses. (8) Using a similar design of physician responses to clinical vignettes, we sought to evaluate a potential bias toward action, such as testing or referral, for patients with unexplained medical complaints.

METHODS

Over several months, 2 of us (AK, IG) identified 60 patients in our practices who had (1) unusual medical complaints, (2) no clear diagnosis, and (3) no apparent need for urgent care. After careful consideration, our team selected 5 cases that best fit the above criteria and reflected the widest spectrum of clinical presentations encountered in primary care settings.

After removing identifying patient information, we wrote each case up as a clinical vignette, then presented all 5 cases to primary care physicians affiliated with 3 major academic centers. For each case, respondents were asked to provide:

* the most likely diagnosis and their level of confidence in that diagnosis (on a scale of 1 [no confidence] to 10 [complete confidence])

* a management strategy (testing, consulting with a specialist, referral to the emergency department [ED], prescribing medication, or follow-up only) and their level of confidence in that choice.

Physicians were asked to estimate the frequency of such cases in their practice, as well.

Preparation of the data (cleaning, sorting, and filtering) was carried out using JMP v9.0 (SAS Institute, Cary, NC), and analyses were conducted with SPSS v19.0 (IBM, Chicago, Ill). We used descriptive statistics to represent the data and chi-square and ANOVA to compare physicians' decisions (action vs follow-up). Nonparametric tests were used to compare levels of confidence for diagnosis and management.

RESULTS

We surveyed a convenience sample of 130 primary care physicians affiliated with academic medical centers, 100 of whom responded. Most respondents (62%) were female, and 86% were certified in family medicine. The average age was 45 years (range 30-68 years), with a mean time out of medical school of 17 years (range 1-26 years). Respondents were born in 14 different countries and had undergone medical training in Europe, the United States, or Israel.

The diagnoses and management approaches selected for each clinical vignette are presented in TABLE 1. For each case, an average of 22 diagnoses (range 18-25) were proposed. Most physicians (87%; P<.01) indicated that they would choose some type of action (testing, consulting, sending the patient to the ED, or prescribing medication) rather than follow-up alone (TABLE 2). Respondents were able to choose multiple management strategies.

For all 5 cases, the physicians had more confidence in their patient management approach than in their diagnosis (5.6 vs 4.3; P<.001). On average, men had higher levels of confidence than women for both diagnosis and management (P<.05). Other demographic characteristics, including age, experience, certification, and site of training, were not predictive of confidence level.

Respondents estimated that 10% to 20% of their own patients present with unusual and unexplained symptoms, like the patients in the clinical vignettes.

DISCUSSION

Patients with undiagnosed signs and/or symptoms present a significant challenge in primary care. In such cases, physicians prefer a work-up to follow-up, with a confidence level in their management strategy that is higher than for their diagnostic hypotheses. There appears to be a stronger perceived need to "do something" than to engage in watchful waiting and follow-up.

* Symptoms subside without treatment. Notably, in all the cases that formed the basis for the clinical vignettes used in our survey, the patients' complaints eventually subsided, with no specific therapy. In some cases of unclear diagnosis, an active work-up may be justified; in others, watchful waiting before testing for unexplained complaints may be preferable.

* Action bias. The preference for action over inaction in all the cases presented suggests what has been described as "action bias." (9) The term is derived from sports; in soccer penalty kicks, for example, it applies to goalkeepers who jump before they can see the kick direction and miss. (10)

According to the norm theory," such errors of commission derive from players' perception that they are expected to act. (10) Conversely, in instances in which inaction is the norm, an omission bias prevails, as people tend to judge acts that are harmful as worse than omissions that are even more harmful. (10) In medicine, action bias has been found to influence clinical practice and contribute to overuse of both diagnostic testing and procedures. (12-14)

* Gender difference. Gender has been shown to affect self-perception in cognitive bias. (15) In a study of confidence levels among undergraduate students, overconfidence was found to be more prevalent among males than females, particularly for incorrect answers. (16) This observation may relate to the gender differences in our study in physicians facing diagnostic uncertainty.

* Study limitations. Our research was limited by the nature and type of our sample, but because the inclination to act was found in both immigrant and native practitioners, the observation of action bias could be generalizable to all primary care physicians. The clinical vignettes we chose may not be representative of commonly seen cases of medically unexplained symptoms. Also, our questionnaire was not tested beyond at-face validity. It is possible, too, that nonresponders would be less inclined to action in the face of uncertainly. With the high (77%) response rate to our survey, however, their inclusion would be unlikely to strikingly alter the results.

Another limitation inherent to the design of our study is that physicians may respond to vignettes in a way that is substantially different than their response in actual practice. In a practice setting, physicians are able to listen to a full narrative and apply various doctor-patient communication tools, which are especially important in the context of unexplained complaints. (17)

On the other hand, the artificial setting may reduce the fear of litigation. Our observation of greater confidence in the need for action than for the diagnostic hypothesis is consistent with testing overuse in field studies. (6) The fact that our survey went only to physicians affiliated with academic centers is another potential limitation, although it is not clear whether these clinicians differ from nonacademic physicians in their approach to unexplained complaints.

Finally, the design of this study did not allow us to explore the reasons for action bias, a task that might be addressed in focus groups or interviews.

* A closer look at bias. Our findings suggest a need for more in-depth research on potential biases that drive medical overuse, as part of an overall strategy to improve physicians' approach to medically unexplained symptoms. (17) Remedies may require training, practice and failure feedback, quality improvement tools, and innovative management strategies. (1,18)

Uncertain diagnosis appears to be a frequent challenge in primary care settings. In the face of uncertainty, weighing the potential harms of overtesting vs follow-up and facilitating an informed decision-making process with the patient may lead to a reduction in action bias, (19) and thus, in the increased testing and higher health care consumption that often result.

ACKNOWLEDGEMENT

The authors thank Steven R. Simon, MD, MPH, for his help with the preparation of this manuscript.

References

(1.) Nimnuan C, Hotopf M, Wessely S. Medically unexplained symptoms: an epidemiological study in seven specialities. J Psychosom Res. 2001;51:361-367.

(2.) Swanson LM, Hamilton IC, Feldman MD. Physician-based estimates of medically unexplained symptoms: a comparison of four case definitions. Fam Pract. 2010;27:487-493.

(3.) Thomas KB. Temporarily dependent patient in general practice. BMJ 1974;1:625-626.

(4.) Jones R, Barraclough K, Dowrick C. When no diagnostic label is applied. BMJ. 2010;340:1302-1304.

(5.) Todd JW. Wasted resources, investigations. Lancet. 1984;2: 1146-1147.

(6.) van der Weijden T, van Velsen M, Dinant GJ, et al. Unexplained complaints in general practice: prevalence, patients' expectations, and professionals' test-ordering behavior. Med Decis Making. 2003;23:226-231.

(7.) Brody H. From an ethics of rationing to an ethics of waste avoidance. N Engl J Med. 2012;366:1949-1951.

(8.) Ayanian JZ, Berwick DM. Do physicians have a bias toward action? A classic study revisited. Med Decis Making. 1991;11: 154-158.

(9.) Part A, Zeckhauser R. Action bias and environmental decisions. J Risk Uncertain. 2000;21:45-72.

(10.) Bar-Eli M, Azar OH, Ritov I, et el. Action bias among elite soccer goalkeepers: the case of penalty kicks. J Econ Psychol. 2007;28:606-621.

(11.) Kahneman D, Miller DT. Norm theory: comparing reality to its alternatives. Psychol Rev. 1986;93:136-153.

(12.) Doust J, Del Mar C. Why do doctors use treatments that do not work? BMJ. 2004;328:474-475.

(13.) Scott IA. Errors in clinical reasoning: causes and remedial strategies. BMJ. 2009; 338:22-25.

(14.) Cohain JS. Is action bias one of the numerous causes of 'unnecaesareans'? Midwif Dig. 2009; 19:495-499.

(15.) Beyer S, Bowden EM. Gender differences in self-perceptions: convergent evidence from three measures of accuracy and bias. Pers Soc Psychol Bull 1997;23:157-172.

(16.) Lundeberg MA, Fox PW, Punccohar J. Highly confident but wrong: gender differences and similarities in confidence judgments. J Educ Psychol. 1994;86:114-121.

(17.) Heijmans M, Olde Hartman TC, van Weel-Baumgarten E, et el. Experts' opinions on the management of medically unexplained symptoms in primary care. A qualitative analysis of narrative reviews and scientific editorials. Faro Pract. 2011;28: 444-455.

(18.) Croskerry P, Norman G. Overconfidence in clinical decision making. Am J Med. 2008; 121 (5 suppl):S24-S29.

(19.) Feinstein AR. The 'chagrin factor' and qualitative decision analysis. Arch Intern Med. 1985;145:1257-1259.

Alexander Kiderman, MD; Uri Ilan, MD *; Itzhak Gur, MD; Tali Bdolah-Abram, BSc; Mayer Brezis, MD, MPH

Clalit Health Services, Department of Family Medicine and the Center for Clinical Quality and Safety, Hadassah-Hebrew University Medical Center, Jerusalem, Israel

brezis@mail.huji.ac.il

The authors reported no potential conflict of interest relevant to this article.

This work was presented as a poster at the 2011 annual meeting of the Association of Family Physicians in Tel Aviv.

* Equal contributor.

CORRESPONDENCE

Mayer Brezis, MD, Center for Clinical Quality & Safety, Hadassah-Hebrew University Medical Center, 91120 Jerusalem, Israel; brezis@mail.huji.ac.il
TABLE 1
Little consensus on diagnoses and management strategies

Clinical vignette       Diagnostic hypotheses   Recommended management
                                                strategies

Case 1                  Neurologic /cord        Tests:
A 23-year-old man in    compression * DVT *     * Blood work: CBC,
good health, with no    Musculoskeletal           [B.sub.12], folic
history of trauma,      condition *               acid, glucose, CRP,
reports a recent        Psychological             ESR, TSH, iron,
decrease in tactile     disorder * Disc           zinc, VDRL, zoster
perception on his       herniation * MS *         antibodies,
right leg. On           Trauma * Tumor *          creatinine, liver
examination,            Vascular disease *        enzymes
sensation is            Neuroma * Diabetes *
decreased over a 3x3    Lead poisoning *        * Imaging: maging:
cm area on the back     Nutritional problem *     Lumbar/chest x-ray,
of the knee; physical   Leprosy                   CT, MRI, US
and neurological
exams are otherwise                             * Skin biopsy
unremarkable.
                                                Consult: Neurology,
                                                orthopedic,
                                                dermatology

                                                Therapeutic trial:
                                                * Corticosteroid
                                                  injection, NSAIDs,
                                                  acyclovir,
                                                  [B.sub.12],
                                                  [B.sub.6],
                                                  [B.sub.1],
                                                  amitriptyline

                                                * Physiotherapy

Case 2                  Tumor * Celiac          Tests:
A 69-year-old woman     disease * GI            * Blood work: Kidney
in good health (with    (gastritis, gastric       function,
well-managed            ulcer, GERD,              creatinine, TSH,
hypertension)           dyspepsia) *              amylase, glucose,
presents with nausea    Medication adverse        prolactin, iron,
--unrelated to eating   effect *                  ferritin, PT, PTT,
--of one month's        Hypernatremia *           CMV, EBV antibodies
duration. She no        Psychological
other symptoms and no   condition * Vertigo *   * Imaging: Gastros US,
signs of depression     Hernia * Elevated         head CT, upper GI
or anxiety. Physical    intracranial pressure     series, , EKG, chest
and neurological        * Liver disease *         x-ray
exams are normal, as    Neurologic/
is biochemistry         ophthalmologic          * Helicobacter pylori,
testing.                disease * UTI * Gall      urea breath test,
                        stones/cholecystitis      urinalysis, occult
                        * Uremia * Diabetes *     blood test, postural
                        Amebiasis                 testing, oncologic
                                                  markers, hepatitis B
                                                  and C, fecal test

                                                Consult:
                                                Ophthalmology,
                                                neurology, ENT

                                                Therapeutic trial:
                                                * PPI, domperidone

                                                * Stop BP meds
                                                  (diuretic and ACE
                                                  inhibitor)

Case 3                  Neurologic * GI         Tests:
A healthy 50-year-      (stomach ache,          * Blood work: Liver
old man reports         irritable bowel,          enzymes, herpes
constant pain in his    Crohn's disease,          antibodies, tumor
right flank, which      colitis) *                markers, ERCP
began 2 years ago. On   Nephrolithiasis *
examination, a 1x2 cm   Diverticulitis *        * Imaging: CT-IVP,
area over the right     Radiated/skeletal         lumbar x-ray,
upper abdomen is        pain * Colon cancer *     gastroscopy, duplex
sensitive to touch.     Depression *              US, bone scan, MRI,
The remainder of the    Peripheral neuropathy     colonoscopy, barium
physical exam is        * Liver disease *         enema
unremarkable; blood     Psychological
and urine tests and     condition * Hernia *    Consult: Urology,
US and CT of the        Cholecystitis/          gastroenterology, pain
abdomen are normal      gallstones *            clinic, neurology,
and a consultant        Spondylitis *           orthopedic
surgeon finds no        Herniated disc *
pathology.              Stress fracture *       Therapeutic trial:
                        Pancreatitis *          Pain killers (opioids
                        Postherpetic pain *     and nonopioids),
                        Peptic ulcer * Trauma   NSAIDs,
                                                antidepressants,
                                                anxiolytics, lidocaine
                                                injection

Case 4                  Varicella * Impetigo    Tests:
A 3-year-old boy with   * Pyoderma * Bullar     * Blood work: CBC,
normal development      disease * Hydrotic        ESR, biochemistry,
and current             cystic disease *          herpes antibodies,
vaccination status      Allergy * Mosquito        CMV
has a new-onset rash    bites * Unspecified
(1-mm pustules on his   viral illness *         * Imaging: Abdominal
legs and forearms),     Pustulosis * Herpes *     US
with no fever or        Eczema * Scarlet
itching. He had         fever * Strep/staph     * Culture from
chickenpox a year       infection *               pustules
ago.                    Vasculitis *
                        Poisoning * Miliaria    * Throat culture/
                        * Psoriasis *             biopsy
                        Folliculitis *
                        Keratosis *             Consult: Dermatology,
                        Medication side         rheumatology,
                        effect                  infectious disease,
                                                pediatric

                                                Therapeutic trial:
                                                Systemic or local
                                                antibiotics,
                                                acyclovir,
                                                antihistamines, local
                                                antiseptics

Case 5                  Tumor * Stomatitis *    Tests:
A 57-year-old healthy   GI (GERD, upper GI) *   * Blood work:
nonsmoker reports a     Behcet's disease *        Hepatitis B and C,
strange sensation--     SLE * Sjogren's           CBC, ANA, folic
"like a coating over    syndrome * Candida *      acid, biochemistry,
my mouth and tongue"    [B.sub.12] deficiency     iron, herpes
--that makes eating     * Postherpetic pain *     antibodies, HIV,
and drinking            Burn * Diabetes *         VDRL, and other STDs
unpleasant, which       Vascular disease *
he's had for one        Cranial nerve disease   * Imaging:
month. On               * Allergy *               Gastroscopy, dental
examination, tiny       Obstructed salivary       x-ray, head CT, neck
nonsensitive aphthae    glands * STD *            CT, upper abdomen US
are found over the      Thiamine deficiency *
frenulum of his         Glossitis * Pemphigus   * Swab for candida
tongue. Blood count     * Medication side         culture, biopsy
and biochemistry        effects *
testing is normal.      Psychological           Consult: Oral surgery,
                        condition               gastroenterology,
                                                oncology,
                                                rheumatology, ENT,
                                                neurology, dentist,
                                                other family doctors,
                                                psychology

                                                Therapeutic trial:
                                                PPI, miconazole oral
                                                gel, prednisone,
                                                acyclovir,
                                                triamcinolone oral
                                                paste, fluconazole,
                                                vitamins, ice

ANA, antinuclear antibodies; BP, blood pressure; CBC, complete blood
count; CMV, cytomegalovirus; CRP, C-reactive protein; CT, computed
tomography;  CT-IVP, computed tomography intravenous pyelogram; EBV,
Epstein-Barr virus; ED, emergency department; EKG, electrocardiogram;
ENT, ear, nose, and throat;  ERCP, endoscopic retrograde
cholangiopancreatography; ESR, erythrocyte sedimentation rate; GERD,
gastroesophageal reflux disease; GI, gastrointestinal; HIV, human
immunodeficiency virus; MRI, magnetic resonance imaging; NSAIDs,
nonsteroidal anti-inflammatory drugs; PPI, proton pump inhibitor; PT,
prothrombin time; PTT, partial thromboplastin time; SLE, systemic
lupus erythematosus; STD, sexually transmitted disease; TSH, thyroid-
stimulating hormone; US, ultrasound; VDRL,  venereal disease research
lab.

TABLE 2
Management options: Which strategy is best? *

                                          Therapeutic
Clinical vignette           Testing (%)    trial (%)

Case 1: Decreased tactile       46            14
perception on right leg

Case 2: Nausea unrelated        75            44
to eating

Case 3: Pain in the right       40            28
flank of 2 years'
duration

Case 4: Toddler with            24            34
unexplained rash

Case 5: Strange sensation       38            23
in mouth Average                45            29

                            Consultation with   Referral    Follow-up
Clinical vignette            specialist (%)     to ED (%)   only (%)

Case 1: Decreased tactile          30               3          34
perception on right leg

Case 2: Nausea unrelated           36               1           2
to eating

Case 3: Pain in the right          48               1          11
flank of 2 years'
duration

Case 4: Toddler with               56               5           9
unexplained rash

Case 5: Strange sensation          71               0           6
in mouth Average                   48               2          13

ED, emergency department.

* Because respondents were able to choose more than one option, totals
exceed 100%.
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Article Details
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Title Annotation:ORIGINAL RESEARCH
Author:Kiderman, Alexander; Ilan, Uri; Gur, Itzhak; Bdolah-Abram, Tali; Brezis, Mayer
Publication:Journal of Family Practice
Article Type:Survey
Geographic Code:7ISRA
Date:Aug 1, 2013
Words:2982
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