Sidetracks in the diagnosis of gastrointestinal disease

Patients usually visit a physician for a particular reason, which medicine has termed the "chief complaint." As patients often have more than a single complaint, it is common for physicians to lose focus, get distracted, and venture down a path other than the one toward resolution of the chief complaint--in other words, to get sidetracked. The aim of the present review is to describe the nature of diagnostic sidetracking, why it occurs, mechanisms in action, and means to prevent it. During a regular diagnostic process, the physician's suspicions about a diagnosis advance from broad and general to narrow and specific concepts. Each step in the diagnostic process is potentially driven by its own hypothesis, and each individual hypothesis becomes verified or falsified by pointed questions during the history or by medical tests. If a diagnostic process were to focus on the correct diagnosis that eventually explained the chief complaint, the intersections among the consecutively refined diagnostic concepts would converge toward one specific set, with the final diagnosis located inside the nonzero intersection of all consecutive diagnostic concepts. In a faulty diagnostic process, consecutive diagnostic concepts fail to converge, and the final diagnosis and chief complaint do not intersect. In this regard, the physician has pursued a false path and has become sidetracked. The effects of sidetracking range from minimal to disastrous. Sidetracking can delay diagnosis, delay treatment, and waste resources investigating or treating irrelevant medical problems. To avoid sidetracking, physicians should focus on the main problem, avoid getting involved with complementary solutions to secondary medical problems, and verify repetitively during the diagnostic process the relationship between each current working hypothesis and the patient's major medical problem.