How to Get the Right Diagnosis. Randolph H. Pherson

that can—and have been—adapted to the medical profession to reduce errors and improve the quality of health care (see Figure 6).

      SATs came into prominence following the terrorist attacks on September 11, 2001, and the flawed 2002 National Intelligence Estimate on weapons of mass destruction in Iraq as a way to improve the overall quality of analysis in the US Intelligence Community. Over the years, use of the techniques has spread to other parts of the US government, foreign intelligence services, major corporations, and academia.

      The techniques have universal value and utility. Analysis of Competing Hypotheses (ACH), for example, is similar to differential diagnosis in the medical profession.

      The following key practices or concepts in intelligence analysis have the potential to help medical professionals reduce error rates:

      • Recognize how mental mindsets and past experiences can bias a diagnosis (Cognitive Bias and Intuitive Traps).

      • Develop more than one explanation for an illness during the initial diagnosis (Multiple Hypothesis Generation).

      • Challenge preconceived notions generated by a patient’s appearance, age, or race (Key Assumptions Check).

      • Focus on disconfirming evidence to quickly eliminate incorrect diagnoses (Analysis of Competing Hypotheses).

      • Seek out and value the opinions of others working the case (Coordination and Peer Review).

      • Know when to expect deception (Deception Detection).

      Figure 6. Intelligence Tradecraft for Medicine

      In this chapter, we discuss how you can leverage five SATs to gain more knowledge about your condition while helping your doctor make a correct diagnosis. The six techniques are:

      1.Multiple Hypothesis Generation

      2.Analysis of Competing Hypotheses

      3.Indicators Generation

      4.Key Assumptions Check

      5.Premortem Analysis

      6.Structured Self-Critique

      Step-by-step instructions on how to use these techniques can be found in Appendices A-F which contain additional information on when to use them, the value added, their relationship to other techniques, and potential pitfalls to avoid.4

      Multiple Hypothesis Generation: What Is the Range of Explanations for My Condition?

      Instead of telling you X is the problem, let’s explore several options.

      In his book, How Doctors Think, Dr. Jerome Groopman argues that the practice of considering alternative explanations for a medical problem is one of the strongest safeguards against making cognitive errors.5 He quotes one of his colleagues as saying, “I learned to always hold back [and avoid jumping to a conclusion], to make sure that, even when I think I have the answer, to generate a short list of alternatives.”

      Multiple Hypothesis Generation is a technique for generating multiple alternatives for explaining a particular issue, activity, or behavior. It is a key technique in the analyst’s toolkit and is particularly useful when many factors are involved, a high degree of uncertainty exists regarding the diagnosis, and your doctors and/or nurses hold different views.

      The technique helps you, your family, and your doctors avoid—or at least mitigate the power of—several analytic traps, including:

      • Coming to premature closure.

      • Being overly influenced by first impressions.

      • Seizing on the first diagnosis or procedure that looks “good enough.”

      • Focusing on too narrow a range of alternatives.

      • Selecting an explanation that replicates a past success or avoids a previous error.

      The value of first considering multiple diagnoses can be demonstrated with the case of dementia. Dementia can be caused by a wide variety of illnesses, injuries, and other factors. Narrowing down the type of dementia is critical to successful treatment. Individuals with Parkinson’s disease, for example, may have symptoms similar to other types of dementia, but the treatment could be vastly different. The symptoms of dementia can make it hard to pin down the specific type of the disease a patient has.

      Failing to identify the type of dementia can result in poor treatment outcomes due to paradoxical reactions (when a medication causes an unexpectedly opposite reaction to what was intended). For example, individuals with a certain type of dementia called Lewy body typically have a paradoxical reaction to benzodiazepine medications such as Valium. When an agitated patient with Lewy body dementia is prescribed a benzodiazepine medication (which is a typical first-line medication for agitation), instead of calming the patient, the effect is to increase the level of agitation. For these reasons, an attentive doctor should first consider a range of possible forms of dementia and then narrow down the diagnosis to avoid prescribing an incorrect treatment.