Diagnostic excellence in primary care

Diagnostic excellence is based on six fundamental principles of healthcare quality proposed by the Institute of Medicine in 2001, which state that diagnoses must be safe, effective, patient‐centered, timely, efficient, and equitable.


E D I T O R I A L Diagnostic excellence in primary care
The intellectual task of diagnosis performed by medical professionals is a critical decision-making process that is vital for determining a patient's treatment and prognosis. Therefore, diagnostics play a pivotal role in healthcare, particularly in primary care, where patients often present with undifferentiated symptoms that the clinician sorts out and accurately diagnoses. According to William Osler, "medicine is a science of uncertainty and the art of probability." This highlights the creative artistic aspect of medicine, as well as the fact that diagnosis is not always certain or even correct.
Since the publication of "To err is human" in 1999, and more recently in 2015 improving diagnosis in healthcare, the potential for error and need to improve diagnostic safety has been increasingly recognized. 1 Currently, viewing diagnosis through a patient safety lens and striving for diagnostic excellence has significantly changed the field. 2,3 Diagnostic excellence is based on six fundamental principles of healthcare quality proposed by the Institute of Medicine in 2001, which state that diagnoses must be safe, effective, patient-centered, timely, efficient, and equitable ( Figure 1). 2 In summary, it refers to an optimal diagnostic process that accurately describes a patient's condition. 2 Internal medicine has always focused on the evaluation of patients presenting with symptoms and signs and the informed and appropriate ordering of diagnostic tests. This includes their cost-effectiveness, with the goal of providing an explanation of the patients' history, physical examination, and laboratory, radiology, and other tests. 3 Although an ancient art, the application of safety science is a relatively new concept for achieving diagnostic excellence and is well suited as a research topic for general medicine physicians working in primary care.  of care, which is highly prioritized by primary care. Furthermore, only continuous dialogue, follow-up conversations, and monitoring between physicians and patients can address diagnostic uncertainty.
To be effective, patients must be engaged in coproducing the diagnosis by presenting them to their clinicians in a timely manner, accurately describing their symptoms, recounting their time course, engaging in shared decision-making regarding diagnostic possibilities and follow-up, and adhering to monitoring and follow-up plans.
Second, the synergy between the four core functions (4Cs) of primary care and the comprehensiveness inherent in diagnostic excellence is exceptionally high. The 4Cs of primary care essential for quality healthcare include first contact, comprehensiveness, coordination, and continuity. Its achievement not only improves health outcomes for patients but also improves inequalities and costeffectiveness. 4 This definition is consistent with the foundation of diagnostic excellence. 2 To date, research on the diagnostic process has focused on the cycle of collecting and interpreting information for accurate diagnosis and recalling differential diagnoses. However, the diagnostic journey of a patient encompasses many elements that exist before the patient experiences a health problem, along with the patient's family relationships and social context. 5 Therefore, we need to understand that new diagnostic paradigms in diagnostic research must move away from a discipline that mainly aims to list differential diagnoses and improve the accuracy of diagnosis, to one that is more patient-centered and has a social sciences aspect.
Furthermore, diagnostic excellence encompasses diagnostic equity. 5 McDonald states that inequalities in the diagnostic process lead to inequalities in medical outcomes. 5 Specifically, various group attributes and characteristics, including age, sex, race, poverty and handicaps, (e.g., belonging to a sexual minority, or living with a physical disability) can increase the risk of diagnostic inequity, leading to inequitable health outcomes. 5  Additionally, it integrates the biopsychosocial model of care, which is the most important family medicine approach routinely used by primary care physicians. 3 As primary care physicians, we must work to achieve diagnostic excellence while preventing errors through patient-centered diagnostic processes.

AUTH O R CO NTR I B UTI O N S
All authors have access to the information utilized and participated in the preparation of this manuscript.

ACK N OWLED G M ENTS
We thank Dr. Yasuharu Tokuda for his pertinent support with the editorial letter. We also appreciate the team members Dr.

CO N FLI C T O F I NTER E S T S TATEM ENT
None.

DATA AVA I L A B I L I T Y S TAT E M E N T
All relevant data are included in this report.

CO N S ENT FO R PU B LI C ATI O N
All authors have provided their consent for publication.