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Orthopaedic surgeon Sunny Deo has spent three decades diagnosing and treating knee joint issues. In this blog, Sunny argues that the healthcare community needs to take a more nuanced approach to diagnosis and decision making so that it can provide patients with safer, more appropriate treatment options. He reflects on why medicine prefers simple answers and looks at how this affects patient care. He goes on to explore how better data collection and the use of artificial intelligence (AI) could provide a more accurate picture of complexity and allow treatment options to be better tailored to individual patients’ needs. "To know the patient that has the disease is more important than to know the disease that the patient has." William Osler, father of modern medicine, 1849-1919. Diagnosis is the process of identifying the nature of an illness or other problem by examining the symptoms and objective findings from investigations. In modern medicine, it is a key focal point of the assessment and management of all patients. A huge amount of clinical medicine training is focused on the art and science of obtaining a diagnosis, and this focus continues into medical practice. The ease of getting to a diagnosis ranges from the glaringly obvious, the so-called ‘spot diagnosis’, through to cases that are very difficult to solve. In between these extremes there is a range from delayed to missed to incorrect diagnosis. The aim of doctors over the centuries has been to work out diagnoses from patients’ symptoms, presenting features (clinical signs) and, in the past century or so, from the evidence of clinical investigations. Quite often, symptoms, signs and investigations produce consistent patterns, and it is these patterns that are taught to medical and other healthcare professionals. This is how diagnoses and outcomes are portrayed in television series or films—just think back to the last episode of Casualty or Grey’s Anatomy you watched. It's also how things often appear in internet searches and on websites and social media. Seeking simple answers to complex questions However, the reality is different. When a patient is sitting in front of me, what I hear and observe may not exactly be what the textbooks, evidence or research tells me I should be seeing. But because we are wired and trained to recognise patterns, we tend to look for diagnoses and solutions that fit within the well-worn narrative. What if the pattern doesn’t fit the actual diagnosis? There are classic presentations for nearly every condition, and these are what you tend to find at the start of a Google search or when using NHS Choices. The expectation of typical symptoms sometimes means we ignore what we might see as annoying variance, superfluous detail or the patient embellishing the truth. This discordance then causes tension with a very basic trait of humans: when we’re faced with a difficult problem, we still seek the simplest solution. This is an evolutionary feature hardwired into us to optimise survival chances. It means we often believe there is a truth to be found that will provide us with a definite answer. From this answer we will come to the best, and ideally only, ‘correct’ solution. Patients who don’t fit the set patterns of diagnosis may then run into trouble when we offer them what is considered to be the ideal treatment. This is an important problem in clinical thinking, language and practice. As a medical community, we tend to create oversimplified approaches based on research that looks for binary answers to complex questions. This research evidence may be based on a small, highly selective ‘typical’ patient cohort, but its findings and conclusions are then translated on to the entire population. This approach results in poor patient outcomes and experience for a small but significant proportion of patients. Pathways designed for ideal diagnoses can cause harm to patients Over my 30 years as an orthopaedic surgeon, 15 as a knee specialist, I have seen that the assessment and treatment of any given condition isn't quite as predictable as we would like it to be. While many patients fit the pattern we are expecting, some do not. I would empirically put the proportion at 60:40, but some unpublished research we did a decade ago suggested the proportion of truly ‘typical’ case presentations for a common condition is much lower. For example, we found that in the case of suspected meniscal tear, this diagnosis actually applied to only 33% of patients with a variety of other diagnoses accounting for the rest. It gets worse when large organisations start to lump patients into a category by condition in a ‘one diagnosis fits all’ strategy. When this approach is taken, there are winners and losers. The winners are those patients whose condition very closely matches the classic presentation of a given condition in isolation. Let’s take the example of knee osteoarthritis—patients with the ‘right type’ of symptoms, physical signs and x-ray changes are generally more likely to do well. Their recovery is more likely to sit within the knowledge base of treating the condition that has evolved over the past half-century. In contrast, patients whose symptoms and test results fall outside of this category may be less likely to do well or recover in the predicted timeframe. This also applies to patients with additional diagnoses or conditions, often termed comorbidities, which may interact, usually in a bad way, with the condition at hand. Failure to consider other diagnoses, either by over-focus on one condition causing wilful ignorance, inattention or lack of attention, may lead to unexpected poor outcomes from a given treatment. It may also mean that the symptoms from the condition that the patient presents with are worse than expected. This doesn’t mean that they won't gain any benefit from a particular treatment, but the risks and potential outcomes may not be communicated adequately by the patient’s healthcare team, if at all. For example, for patients with painful knee osteoarthritis, the current diagnosis to treatment logic runs like this: Knee osteoarthritis is a painful condition. Total knee replacement surgery is a validated safe procedure with significant improvements in quality of life. Other treatment options do not produce as much positive therapeutic benefit compared to total knee replacement surgery. Therefore, total knee replacement surgery is the only treatment for painful knee osteoarthritis. However, there are patients for whom knee replacement surgery is not a safe or practical option, and these patients may benefit from alternative treatments that are not currently offered as they are seen as providing limited benefit. This may be because the participants in trials undertaken over the years had varying diagnoses, meaning that true comparisons of alternative options may have had additional interacting diagnoses or failed to account for differing severity. Understanding the spectrum of complexity As healthcare professionals, we have a duty to diagnose patients as accurately as possible. In orthopaedics, if treatments go wrong or are poorly undertaken, it may lead to prolonged or permanent pain or disability, and we obviously want to avoid this as much as possible. Incomplete identification and documentation of all relevant symptoms and health conditions can potentially lead to an increased risk of treatment failure and complications. Our priority should be to identify these diagnoses or diagnostic clusters as accurately as possible. I think these are basic principles we need to apply to create better systems and improved care for as many patients as possible. In my view, there are grades of ‘atypical patients’ and I have devoted the past decade to trying to demonstrate this, with surprisingly stiff resistance from peer-reviewed journals and funding organisations. I have tried to move away from lumping all patients into a single category. I have done some research on seemingly straightforward soft tissue problems and osteoarthritis in the knee. My initial analysis suggests that we need to collect more detailed and accurate data, rather than simplifying data into minimum datasets. This is where AI can really come into its own, not as a diagnostic tool initially, but as a powerful aid to unlocking and interpreting some of the diagnostic interactions that create problems for patients. However, the use of AI does need to be undertaken with extreme care and consideration, and this isn’t always happening currently. To offer healthcare that is truly person-centred, we need to look beyond our well-worn simple answers and solutions. By using better data and new machine learning tools to understand the nuances of each person’s condition and how it relates to their wider health, we can offer treatment options that are safer, kinder and more cost-effective. Share your views We would love to hear your views on the issues highlighted in Sunny’s blog Are you a clinician who would like to share your experiences? Do these challenges resonate with you? Or are you a patient who has experienced complications because of poor, missed or inadequate diagnosis? Add your comment below (you will need to be a hub member and signed in) or contact us at [email protected] and we can share your story anonymously. Related content on the hub: Using data to improve decision making and person-centred care in surgery: An interview with Sunny Deo and Matthew Bacon Diagnostic errors and delays: why quality investigations are key

The current consultation by the Department of Health and Social Care, ‘Leading the NHS: proposals to regulate NHS managers’ defines professional standards as “…the values, behaviours and competencies that managers will be expected to demonstrate.” In this blog, Lesley Parkinson, Executive Director at Restorative Thinking, and author of 'Restorative Practice at Work', explains what restorative and relational practice is and why this needs to be explicitly written into the professional standards being developed to improve relationships and accountability. There is currently not a set of recognised professional standards for NHS managers and I understand that NHS England is in the process of developing these. My hope is that restorative and relational practice will be included. This consists of a set of principles, processes and skills that guide our thinking, language and behaviours, and help us to continually build and improve our relationship skills. The graphic below gives a little more detail about what restorative and relational practice offers: If these behaviours and processes can be coherently and explicitly written into the professional standards being developed, they will go some way to improving relationships and accountability. This will have a positive impact on patient safety, as there will be less likelihood of people carrying grudges, feeling that things aren’t fair and other emotional distractions that prevent us from giving our full attention to the patients in front of us. There is already some guidance around workplace behaviours in the NHS; ‘compassionate leadership’ and ‘civility and respect’ spring to mind. Restorative and relational practice adds the detail of processes and language to deliberately foster equality of voice and respectfully challenge each other when we see, hear or feel something that isn’t right; this could be the way someone speaks to us or something we observe taking place that looks wrong or unsafe. Approaching someone in order to challenge them is a key relationship skill that needs deliberate and specific attention. If our approach is accusatory, we will likely meet a defensive or argumentative response; this interaction could damage a relationship immediately and in the long term. Restorative and relational practice helps us to navigate this tricky territory so that we learn how to respectfully challenge each other: to pause judgement; invite perspectives; discuss feelings and expectations; end with a solution in which there’s clear accountability and agreement. The Restorative Thinking team is currently delivering workshops with NHS trusts to develop these particular skills, but I’m afraid there’s no quick fix. The language and processes we use are based on a group of psychological and behavioural sciences and it’s key that we understand and grasp these before putting the theory into practice. New research from the Imperial College Business School shows how leaders can make constructive challenge not just possible but an integral part of a thriving organisational culture. In terms of the current Department of Health and Social Care consultation, I’ve observed the most effective regulation is done within teams and departments, person to person. It's clear that too many leaders, managers and staff lack the relationship skills to regulate each other; this is what needs to be addressed so that all NHS staff (whatever their role) can give their full attention to patient care and patient safety. The good news is that the Restorative Thinking team is developing learning options: podcasts, videos and paper resources, to help facilitate this ‘relationships education’ and we are building a self-guided learning page on our website to be launched in 2025. We already offer a short e-learning course and we've started to publish freely available podcasts on this theme. We are also partnering with the organisation AQUA to help NHS organisations to design and deliver safer care for patients by including restorative and relational practice into staff inductions, staff training, organisational development and Board development sessions.

'The Family Oops and Burns First Aid' is a free children's book written by Kristina Stiles, beautifully illustrated by Jill Latter, created to support children and their families learning about burns prevention and first aid principles together. The book describes an accident prone family who are not burns aware, who have to go to school to learn about burn safety and first aid principles within the home. The book is aimed at KS1 children and their families, and is available as hard copy book by request from Children's Burns Trust and also as an audio/video book via YouTube.

It has become fashionable to purge the term ‘error’ from the safety narrative. Instead, we would rather talk about the ‘stuff that goes right’. Unfortunately, this view overlooks the fact that we depend on errors to get things right in the first place. We need to distinguish between an error as an outcome and error as feedback, writes Norman MacLeod in this blog for the hub. In an increasingly litigious world, intolerant of failure, error has become inextricable linked with fault and blame. Here, error is considered in hindsight by agents in positions of power or with specific agendas. Something happened and someone must pay. Clichés such as ‘error is natural’ or ‘no one intends to make a mistake’ carry little weight. Unfortunately, this interpretation of ‘error’ feeds into debates in the safety domain but simply rejecting the term misses the point. To understand the importance of error we need to reflect on the nature of the world. Imagine a small pile of sand on a table. As you add more grains of sand, the cone will build, maintaining its shape until, eventually, the next single grain will trigger a cascade. Sand will slip down the side of the cone until a new shape is stabilised. And, so, the process goes on. The cone is stable under most circumstances but just a single grain of sand can trigger a transition to a new stable state. The world, then, exists in a state of self-organised criticality. This is important. If the world was too stable, it would not be able to respond to change. Instability, then, is an adaptive property. It also means that work must contend with this inherent instability. We need to be constantly adapting to events as we encounter them, which might not be how we anticipated them at the outset. It is this mismatch between ‘expected’ and ‘actual’ that is one source of error. But there is a more fundamental process that gives rise to error. All action flows from decisions made by a brain encased in bone. It has no direct access to the outside world. The brain acts like a Bayesian probability engine. The brain creates a set of expectations about the nature of the world, and these are compared with sensory inputs. Any discrepancies – errors – are resolved until our perceived reality meets a threshold. Our investment in establishing ‘reality’ is just enough to support whatever action is needed to achieve our goals. This last statement presupposes that all action is goal directed. Error, in this context, is feedback from the world about the correlation between our actions and our progress towards our goal. In fact, error is information that reduces uncertainty. In this sense, error allows us to fine-tune our actions. Studies of airline pilot performance reveal that about a third of errors committed by crew go unnoticed. They are seen by the trained observer, but not by the perpetrators, and barely 1% of these errors have any sort of impact on the operation of the aircraft. This suggests two things: first, in aviation at least, the operation is resilient and can cope with error; second, the consequence of error does not seem to impinge upon the crew’s understanding of what is happening to the extent that they need to take any action. However, when an error does come to the attention of the crew, a response is needed. Again, studies show that a significant proportion of detected errors are simply ignored by crew. Fewer than half require a positive intervention. It is fashionable to talk about error ‘management’. In fact, crew do not ‘manage’ errors: instead, they respond to the new set of circumstances created by the error. Error is the trace you leave behind, like the wake of a ship. You play what is in front of you and don’t look back. But what about the ‘things that go right’? Here is a game you can play. Imagine you are watching someone in the workplace. How do you know things are going right? Probably, it’s because you haven’t seen anything going wrong. We are designed to detect ‘wrong’ because that is what will save our lives. It’s an evolutionary thing. We are blind to ‘right’ because that is simply our expectations – the brain’s prediction – being met. That said, have you ever been impressed by something you have seen at work? Again, this is our prediction not being met, but in a surprising way rather than a negative way. Surprises, like failures, are learning opportunities. Both allow us to refine our internal representations of tasks, leading to better goal specification and richer action sequences directed at attaining that goal. Error, then, is not only good but also essential. The original meaning of ‘error’ was to wander. It is not the wandering that really matters but the path people were trying to follow in the first place. Key take away points: 1. After a process failure, the goal is to explain the gap between planned and actual. Culpability comes a distant second. 2. Most responses to adverse events merely shift the point of failure. The work will be no less variable and the role of error will not change. 3. If you really need a 'Just Culture' policy it suggests that the people with power do not understand error.