Diagnostic challenges in primary care: Identifying and avoiding cognitive bias

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doi:doi: 10.12788/jfp.0380

Applied Evidence

Diagnostic challenges in primary care: Identifying and avoiding cognitive bias

J Fam Pract. 2022 April;71(3):124-132 | doi: 10.12788/jfp.0380

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References

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The consequences of a missed and delayed PMR diagnosis range from seriously impaired quality of life to significantly increased risk of vascular events (eg, blindness, stroke) due to temporal arteritis.¹³ Early diagnosis is even more critical as the risk of a vascular event and death is highest during initial phases of the disease course.¹⁴

FPs often miss this Dx. A timely diagnosis relies almost exclusively on an accurate, thorough history and physical exam. However, PCPs often struggle to correctly diagnose PMR. According to a study by Bahlas and colleagues,¹⁵ the accuracy rate for correctly diagnosing PMR was 24% among a cohort of family physicians.

The differential diagnosis for PMR is broad and includes seronegative spondyloarthropathies, malignancy, Lyme disease, hypothyroidism, and both RA and OA.¹⁶

PCPs are extremely adept at correctly diagnosing RA, but not PMR. A study by Blaauw and colleagues¹⁷ comparing PCPs and rheumatologists found PCPs correctly identified 92% of RA cases but only 55% of PMR cases. When rheumatologists reviewed these same cases, they correctly identified PMR and RA almost 100% of the time.¹⁷ The difference in diagnostic accuracy between rheumatologists and PCPs suggests limited experience and gaps in fund of knowledge.

Making the diagnosis. The diagnosis of PMR is often made on empiric response to corticosteroid treatment, but doing so based solely on a patient’s response is controversial.¹⁸There are rare instances in which patients with PMR fail to respond to treatment. On the other hand, some inflammatory conditions that mimic or share symptoms with PMR also respond to corticosteroids, potentially resulting in erroneous confirmation bias.

Some classification criteria use rapid response to low-dose prednisone/prednisolone (≤ 20 mg) to confirm the diagnosis,¹⁹while other more recent guidelines no longer include this approach.²⁰ If PMR continues to be suspected after a trial of steroids is unsuccessful, the PCP can try another course of higher dose steroids or consult with Rheumatology.

Case 2

A woman in her mid-40s presented to a PCP’s office with a chief complaint of dyspepsia and bloating.^a The patient was attending a meeting in New York City, and this was her first visit to this physician. The patient previously had been treated for these symptoms by her hometown PCP and gastroenterologist.

Continue to: A full history...