Intended for healthcare professionals


Stop the silent misdiagnosis: patients’ preferences matter

BMJ 2012; 345 doi: (Published 08 November 2012) Cite this as: BMJ 2012;345:e6572
  1. Albert G Mulley, director1,
  2. Chris Trimble, adjunct professor1,
  3. Glyn Elwyn, visiting professor1
  1. 1Dartmouth Center for Health Care Delivery Science, Dartmouth College, Hanover, New Hampshire, USA
  1. Correspondence to: G Elwyn elwyng{at}
  • Accepted 6 September 2012

Correct treatment recommendations require accurate diagnosis not only of the medical condition but of patients’ treatment preferences. Al Mulley, Chris Trimble, and Glyn Elwyn outline how to ensure that preferences are not misdiagnosed

In recent decades, rapid advances in the biosciences have delivered an explosion of treatment options. This is good news for patients, but it makes medical decision making more complicated. Most critically, an accurate medical diagnosis is no longer sufficient to identify the proper treatment. Just as important is an accurate preference diagnosis.1 Every option for treatment (a term that we use broadly here, to include procedures, tests, and even watchful waiting) has a unique profile of risks, benefits, and side effects. Doctors, generalists as well as specialists, cannot recommend the right treatment without understanding how the patient values the trade-offs. Regrettably, patients’ preferences are often misdiagnosed. We outline a method for making better preference diagnoses.

Historical perspective

“Listen to the patient: he is telling you the diagnosis,” William Osler urged students he taught at Johns Hopkins and Oxford more than a century ago. Osler knew that the patient’s story was often critical to an accurate diagnosis. Like many of his contemporaries, Osler saw diagnosis as the medical profession’s foundational skill. The right treatment, after all, depended on the right diagnosis. Generations later, skill in diagnosis remains a source of professional pride for many physicians, while the spectre of a misdiagnosis or missed diagnosis can provoke sleepless nights.

Medicine has changed since Osler’s day, in that there are now more diagnostic technologies and more treatment options. Although the rising accuracy of diagnostic tests has allowed doctors to rely less on listening when determining the cause of symptoms,2 listening is growing in importance when deciding which of the many treatment options best fits each patient’s priorities.

The …

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