title: Unexplained complaints in primary care: evidence of action bias.
abstract: OBJECTIVE
  Primary care physicians sometimes encounter patients with clinical complaints that do not fit into a recognized diagnostic pattern. This study was undertaken to assess the way physicians respond to patients whose symptoms are unusual or unexplained that is, what approach they take in the absence of a working hypothesis.
  
  
  METHODS
  We surveyed 130 primary care physicians affiliated with 3 academic centers in Israel, presenting 5 clinical vignettes describing patients who had unusual complaints, no clear diagnosis, and no apparent need for urgent care. We asked physicians to provide the most likely diagnosis for each case and to rate their level of confidence in that diagnosis;respondents were also asked to provide a management strategy for each case and their level of confidence in the chosen approach. Finally, we asked the physicians to estimate how many of their own patients have presentations similar to the individuals in the clinical vignettes.
  
  
  RESULTS
  Physicians proposed, on average, 22 diagnoses for each case. Most indicated that they would choose action (testing, consulting, sending the patient to the emergency department, or prescribing) rather than follow-up only (87% vs 13%; P<.01). Respondents' confidence in the management approach they had chosen for all the cases was higher than their confidence in the diagnoses (5.6 vs 4.3, respectively, on a scale of1-10; P<.001). Physicians estimated that 10% to 20% of the patients they see in their practice have unusual or unexplained symptoms that are difficult to diagnose.
  
  
  CONCLUSIONS
  Uncertain diagnosis is a regular challenge for primary care physicians. In such cases, we found that physicians prefer a workup to follow-up, an inclination consistent with“action bias.”
authors.affiliation: Clalit Health Services, Department of Family Medicine and the Center for Clinical Quality and Safety, Hadassah-Hebrew University Medical Center, Jerusalem, Israel. Email: brezis@mail.huji.ac.il.
authors.forename: Alexander
authors.initials: A
authors.lastname: Kiderman
authors.forename: Uri
authors.initials: U
authors.lastname: Ilan
authors.forename: Itzhak
authors.initials: I
authors.lastname: Gur
authors.forename: Tali
authors.initials: T
authors.lastname: Bdolah-Abram
authors.forename: Mayer
authors.initials: M
authors.lastname: Brezis
mesh_terms: D000328:Adult; D000368:Aged; D002983:Clinical Competence; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care / Q000592:standards*; D011795:Surveys and Questionnaires