Jump to ContentJump to Main Navigation
Show Summary Details
More options …


Official Journal of the Society to Improve Diagnosis in Medicine (SIDM)

Editor-in-Chief: Graber, Mark L. / Plebani, Mario

Ed. by Argy, Nicolas / Epner, Paul L. / Lippi, Giuseppe / McDonald, Kathryn / Singh, Hardeep

Editorial Board: Basso , Daniela / Crock, Carmel / Croskerry, Pat / Dhaliwal, Gurpreet / Ely, John / Giannitsis, Evangelos / Katus, Hugo A. / Laposata, Michael / Lyratzopoulos, Yoryos / Maude, Jason / Newman-Toker, David / Singhal, Geeta / Sittig, Dean F. / Sonntag, Oswald / Zwaan, Laura

See all formats and pricing
More options …

Diagnosis is a team sport – partnering with allied health professionals to reduce diagnostic errors

A case study on the role of a vestibular therapist in diagnosing dizziness

Dana B. ThomasORCID iD: http://orcid.org/0000-0002-4194-4740 / David E. Newman-Toker
  • Corresponding author
  • Department of Neurology and Otolaryngology, The Johns Hopkins University School of Medicine, CRB-II, Room 2M-03 North 1550 Orleans Street, Baltimore, MD 21231, USA
  • Email
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
Published Online: 2016-05-31 | DOI: https://doi.org/10.1515/dx-2016-0009


Background: Diagnostic errors are the most common, most costly, and most catastrophic of medical errors. Interdisciplinary teamwork has been shown to reduce harm from therapeutic errors, but sociocultural barriers may impact the engagement of allied health professionals (AHPs) in the diagnostic process.

Methods: A qualitative case study of the experience at a single institution around involvement of an AHP in the diagnostic process for acute dizziness and vertigo. We detail five diagnostic error cases in which the input of a physical therapist was central to correct diagnosis. We further describe evolution of the sociocultural milieu at the institution as relates to AHP engagement in diagnosis.

Results: Five patients with acute vestibular symptoms were initially misdiagnosed by physicians and then correctly diagnosed based on input from a vestibular physical therapist. These included missed labyrinthine concussion and post-traumatic benign paroxysmal positional vertigo (BPPV); BPPV called gastroenteritis; BPPV called stroke; stroke called BPPV; and multiple sclerosis called BPPV. As a consequence of surfacing these diagnostic errors, initial resistance to physical therapy input to aid medical diagnosis has gradually declined, creating a more collaborative environment for ‘team diagnosis’ of patients with dizziness and vertigo at the institution.

Conclusions: Barriers to AHP engagement in ‘team diagnosis’ include sociocultural norms that establish medical diagnosis as something reserved only for physicians. Drawing attention to the valuable diagnostic contributions of AHPs may help facilitate cultural change. Future studies should seek to measure diagnostic safety culture and then implement proven strategies to breakdown sociocultural barriers that inhibit effective teamwork and transdisciplinary diagnosis.

This article offers supplementary material which is provided at the end of the article.

Keywords: Diagnosis; diagnostic errors; dizziness; misdiagnosis; physical therapy specialty; vertigo


Diagnostic errors are the most common, most costly, and most catastrophic of medical errors [14]. A recent national academy of medicine (NAM, formerly Institute of Medicine [IOM]) report on Improving Diagnosis in Healthcare estimated that every American will experience at least one diagnostic error in his/her lifetime, sometimes with devastating consequences such as permanent disability or death [5]. Building on patient safety principles developed in tackling therapeutic errors, the NAM committee placed strong emphasis on teamwork to improve diagnosis, making their first overall recommendation to “facilitate more effective teamwork in the diagnostic process among health care professionals, patients, and their families” [5]. In this, they specifically called out interprofessional collaboration around diagnosis to include nurses, therapists, and other allied health professionals:

“The diagnostic process hinges on successful intra- and interprofessional collaboration among health care professionals, including primary care clinicians, physicians in various specialties, nurses, pharmacists, technologists, therapists, social workers, patient navigators, and many others. Thus, all health care professionals need to be well prepared and supported to engage in diagnostic teamwork. The roles of some health care professionals who participate in the diagnostic process have been insufficiently recognized… nurses are often not recognized as collaborators in the diagnostic process, despite their critical roles in ensuring communication, care coordination, and patient education; monitoring a patient’s condition; and identifying and preventing potential diagnostic errors.” [5]

Medical diagnosis is historically and legally considered a physician’s responsibility. Allied health professionals (AHPs) such as nurses, speech language pathologists, and physical therapists (PTs) are often prohibited from making medical diagnoses as part of the legal definitions of their respective scopes of practice. Although certain diagnostic “rights” are granted to some AHPs such as nurse practitioners and physician assistants (PAs), strong sociocultural constraints may limit their role in diagnosis (e.g. only narrowly-defined “nursing diagnoses” or assessment of “minor” medical symptoms). There are reasons to believe, however, that this antiquated view of medical diagnosis needs to change.

First, diagnostic reasoning is already a core job responsibility for most AHPs, even if it is referred to by some other term, such as “triage” or “assessment of functioning”. When a nurse “triages” a patient in the emergency department (ED) or decides whether to call the surgeon to evaluate an ill-appearing post-operative patient, he uses symptoms and signs to determine a patient’s level of illness. When a speech pathologist determines the physiologic nature of a swallowing deficit, she uses pathophysiologic principles to determine the nature of dysfunction. When a vestibular PT identifies which semicircular canals require treatment in benign paroxysmal positional vertigo (BPPV), he uses physical diagnosis skills to differentiate one vestibular disorder from another. These are all examples of applied diagnostic reasoning that drive management or therapy, whether we acknowledge it or not.

Second, AHPs often spend more time with a patient than the physician. They may see patients repeatedly to check on them as inpatients or follow them routinely over time as outpatients. This means that AHPs often have greater exposure to the range of patient symptoms, disease course, and response to therapy, all of which may offer additional insights into the patient’s underlying condition. Failure to integrate this knowledge of the patient’s medical condition into patient care for the purposes of diagnosis needlessly reduces the quality of care and may perpetuate misdiagnoses.

Finally, as medical knowledge becomes increasingly subspecialized, many AHPs now have considerably more expertise than their physician counterparts within their narrow domains of practice. One such domain is the evaluation and treatment of dizziness and vertigo, in which vestibular PTs are often called to evaluate and treat patients with BPPV and other inner ear disorders. Dizziness and vertigo lead to more than 12 million medical visits each year in the US [6, 7]. As dizziness and vertigo are among the most misunderstood and commonly misdiagnosed symptoms in all of medicine [815], it is not uncommon for referred patients to have been misdiagnosed. Failure to effectively leverage AHP expertise to improve patient care may lead directly to misdiagnosis.

In this article we describe a series of five cases presenting dizziness or vertigo in which initial physician diagnoses were not supported by the results of detailed vestibular examinations performed by a vestibular PT. The input provided by the therapist to the physicians resulted in changes in final diagnoses, and consequently, changes in the care that was delivered. We discuss the immediate implications of this case series for optimizing diagnosis of patients with dizziness and vertigo, as well as the broader issue of engaging AHPs in diagnosis across a range of conditions.


This qualitative case study describes an ongoing interaction between a vestibular PT (DBT – “Dana”), a neurological subspecialist in vestibular disorders (DENT – “David”), and Dana’s experience with several groups of physicians in a single medical center from 2011 to 2016. As part of this institutional case study, we report a retrospective, non-consecutive case series of patients presenting with acute dizziness or vertigo who were initially misdiagnosed by physicians and later correctly diagnosed after consideration of examination findings made by the vestibular PT. We also describe the sociocultural changes that have gradually occurred at the medical center with respect to the value placed on physical therapy vestibular examination findings to help with accurate diagnosis. These changes have been coincident with (and perhaps the result of) a series of formal and informal interactions between the PT and physicians as well as mid-level providers. Note that we have deliberately manipulated case demographics to minimize the risk of individual patient or physician discovery by readers. This study was evaluated by the WakeMed Health and Hospitals Institutional Review Board (IRB) and was determined to be exempt from formal IRB review (IRBNet#745256-1).

The PT, with over 24 years’ experience and a certificate of competency in vestibular rehabilitation, has pursued extensive study of neurological and vestibular disorders, including assessment of acute dizziness and vertigo in the ED and acute care setting. The subspecialist neuro-otologist has completed neurology residency (4 years), followed by fellowships in neuro-ophthalmology (1 year) and neuro-otology (2 years). The focus of his clinical practice and research is improving diagnostic accuracy and reducing diagnostic error for patients presenting to the ED with acute dizziness or vertigo. He has a total of over 20 years’ experience since graduating medical school.

The medical center is a large, acute care trauma center and tertiary care hospital. The PT interacts with a mix of physicians and mid-level providers, most commonly hospitalists and internal medicine residents, neurologists and neurological PAs, trauma surgeons and surgical PAs, and cardiology PAs. ED consultation requests for vestibular physical therapy services are usually generated by the hospitalist or neurology practitioners, but sometimes by ED staff. Once patients have been admitted to observation or inpatient status, referrals may be generated by any of the above-listed providers, or may be prompted by other physical or occupational therapists identifying the need for vestibular evaluation during routine therapy sessions.


Interaction between medical subspecialist and vestibular PT

Dana first reached out to David in 2011, after having read one of his articles describing a novel bedside method (called ‘HINTS’) for differentiating strokes from inner ear diseases using eye movement exams in patients presenting acute dizziness and vertigo [16]. The original email, included as an online supplement, makes clear the fundamental dilemma that Dana faced as an AHP. She stated, “As a PT, diagnosis is not within the scope of my practice, and I avoid any documentation that would insinuate diagnosis. I will, in verbal conversations with physicians, at their requests, give them my opinion, based on objective examination findings. I have referred to the HINTS article on several occasions, in hopes of finding physicians who are aware of its huge implications. Most are not aware of the article and do not routinely implement the recommended exam techniques mentioned”. David replied to Dana, and an ongoing channel of communication was opened. Dana would periodically discuss difficult vestibular cases with David, but also difficult interactions with other providers. Some were skeptical of her knowledge base or questioned her authority to provide them with diagnosis-relevant clinical information. David served as a mentor and remote “physician champion” to support her work in local culture change.

Misdiagnosed cases

We use as illustrations here five cases demonstrating diagnostic errors that were prevented by a clarified “team” approach to diagnosis of these patients. These five are representative of a multitude of cases at the medical center where vestibular assessments provided by vestibular PTs have provided substantive information to assist with diagnosis. In all cases, the initial medical diagnosis changed after the medical practitioner and treating team considered input from the physical therapy assessment. One case was admitted and discharged by the trauma service (Case 1). Four cases were admitted and discharged by hospitalists (Cases 2, 3, 4, 5) and two of those cases included the addition of neurology consultation for therapeutic intervention following a correctly identified diagnosis (Cases 4, 5). The cases illustrate a range of errors for both benign and dangerous vestibular disorders (Table 1), with corresponding implications for both diagnostic costs (test overuse) and patient safety (health outcomes). The outcome of this team diagnostic process in each case resulted in effective treatment for the conditions ultimately correctly diagnosed, timely discharge from the acute care setting, and patient satisfaction that their primary symptoms were being addressed.

Table 1:

Diagnostic process and diagnosis label failures in five cases presenting dizziness/vertigo.

Case #1: A young adult fell off the back of a truck, sustaining head trauma

A head computed tomography (CT) obtained in the ED was negative for brain bleed, contusion, or edema. High-resolution CT of the temporal bones showed all inner ear structures intact. The patient’s primary complaint was vertigo. The initial diagnoses by the trauma physician were occipital and right mastoid fractures, along with concussion. The PT’s evaluation, including the evidence-based HINTS [1620] eye exam, revealed subtle direction-fixed left-beating nystagmus with mildly abnormal right horizontal head-impulse test but no vertical skew deviation on alternate cover test, suggesting an acute right traumatic vestibulopathy. Right ear hearing loss was noted on the finger rub test. The patient also had symptoms and signs of BPPV in all three right semicircular canals on positional testing. The PT treated the patient’s BPPV successfully using a sequence of multiple different canalith repositioning maneuvers. All of the positional testing for BPPV was negative on the second day. The patient was independently ambulating without assistive devices and demonstrated only very subtle high-level balance deficits, but was not deemed to be at risk for falls. The patient was given vestibular exercises to continue after discharge. The PT spoke with the trauma PA about the exam findings, adding the following new diagnoses: acute right cochleo-vestibulopathy (likely from labyrinthine concussion, which cannot be detected by CT) and multi-canal post-traumatic BPPV, treated effectively by evidence-based canalith repositioning maneuvers [21, 22]. A plan was made for outpatient audiogram to assess the degree of hearing loss.

Case #2: An elderly patient with mild dementia was admitted with symptoms of intractable nausea and vomiting

The patient was diagnosed with gastroenteritis by the admitting hospitalist. During a routine physical therapy evaluation, the patient’s family member mentioned that the patient had been experiencing intermittent vertigo and dizziness. The patient was found to have symptoms and signs consistent with a right posterior canal BPPV on Dix-Hallpike testing, which was treated with a single canalith repositioning maneuver [21, 22]. The patient had significant vegetative symptoms (i.e. nausea and dry heaving, diaphoresis) at the time of treatment. The PT spoke with the attending hospitalist and conjectured that the nausea and vomiting were symptoms related to BPPV. The hospitalist agreed to progress the patient to a regular diet, and the patient tolerated the diet with no further nausea and vomiting. The next day, the patient was asymptomatic and walking well with the family as per the reported baseline. A repeat Dix-Hallpike test was negative for vertigo or nystagmus. The final diagnosis by the treating physicians was BPPV, not gastroenteritis.

Case #3: A middle-aged adult was admitted with nausea, vomiting, and vertigo

The initial hospitalist internal medicine team diagnosis was stroke. Magnetic resonance imaging (MRI) brain was negative for acute changes. The PT’s evaluation revealed symptoms and signs consistent with right horizontal and posterior canal BPPV. The patient reported a lifelong history of a tendency toward motion sensitivity. At the time of the initial PT’s evaluation, the patient was having significant vegetative symptoms. The patient was initially only able to walk 25 feet and required significant assistance. After 2 days of treatment with multiple canalith repositioning maneuvers, the patient had complete resolution of the right posterior canal BPPV and partial resolution of the right horizontal canal BPPV. At the time of discharge, the patient was walking 100 feet with only stand-by guarding without assistive devices. The patient was discharged with a prescription for outpatient vestibular rehabilitation to continue BPPV treatment. PT examination findings and treatment results were discussed directly with the medicine team on both days directly following physical therapy sessions. The final diagnosis by the physician team was BPPV.

Case #4: A middle-aged patient presented with symptoms of nausea, vomiting, and vertigo

The hospitalist initially diagnosed the patient with BPPV. The patient was unable to fully participate in the initial physical therapy evaluation the next morning due to constant, severe vertigo and nausea. The PT’s interview of the patient revealed a history of head and neck trauma during a work-related incident a few weeks prior. The patient endorsed a few episodes of intermittent vertigo and right ear tinnitus since the trauma, and also confirmed right ear tinnitus at the time of the interview. The physician was notified immediately by phone of the PT’s concern for serious diagnosis, given the patient’s trauma history and constant (non-episodic) vertigo, two important markers of stroke risk [17, 23]. Based on the PT’s concern and the PT’s assertion that the signs and symptoms exhibited by the patient were not consistent with BPPV, the physician ordered neuroimaging [MRI and magnetic resonance angiogram (MRA)], which revealed right vertebral artery dissection and right cerebellar stroke, the final diagnoses. Neurology was consulted and prescribed anticoagulant medication. There was no stroke progression or worsening. The patient’s gait and balance improved over the next few days of acute hospital physical therapy treatment. The patient was transferred to an inpatient rehabilitation hospital for ongoing therapy prior to discharge home.

Case #5: A young adult presented to the ED reporting sudden onset vertigo, nausea, vomiting and unsteady gait 4 days prior, with continued feeling of unsteady gait and mild vertigo upon presentation to the ED

The ED physician ordered a CT scan of the head, which was normal. The ED staff handed the patient over to the hospitalist, who called the vestibular PT and asked that the patient be assessed for BPPV. The PT’s evaluation revealed subtle neurologic signs not noted on prior physician examinations, including mild balance deficits, subtle left facial and right plantar foot numbness, and mild left tongue deviation. The HINTS exam, also performed by the PT, revealed direction-changing horizontal nystagmus in right and left gaze, normal horizontal head-impulse test bilaterally, and no vertical skew deviation on alternate cover test. The PT’s assessment stated concern for central vestibular deficit based on HINTS results [20] and other exam findings. Based on the PT’s vestibular evaluation, which the PT discussed immediately with the physician by phone, the physician ordered a brain MRI, which revealed multiple bilateral cerebral hemisphere and brainstem lesions consistent with multiple sclerosis, the final diagnosis. The patient was admitted and received IV steroid treatments per recommendations of the Neurology team, with plans for outpatient neurology follow-up. At the time of discharge, the patient was independently ambulating without assistive devices. The patient had residual subtle high-level balance deficits, but was not at risk for falls. The patient was given a home balance exercise program.

Sociocultural and structural changes in ‘team diagnosis’ over time at the medical center

The climate of discourse between Dana and the local referring providers was initially very strained. Some practitioners dismissed her comments when she suggested that objective clinical findings were incompatible with the initial medical diagnosis. Due to widely accepted sociocultural norms with respect to physician-AHP interactions, she has felt it necessary to tread very lightly or back down on many occasions. These interactions have often placed Dana in an ethical and moral bind, trapping her between sociocultural practice constraints and an ethical and personal obligation to help her patients. Despite continued resistance to optimal collaboration by some providers, she feels that the environment has improved and more practitioners are becoming receptive, as she and her team of PTs who perform vestibular evaluations and treatments continue to demonstrate the value of their input. Dana’s ability to rely on David as a physician mentor and sounding board was an important facilitator in her success, especially in the early years of this transformation, when resistance was particularly strong.

There was a major nodal point in transforming the sociocultural milieu. This occurred when Dana presented at medical grand rounds to an audience consisting of mostly physicians, discussing the clinical assessment and treatment of patients presenting with acute vestibular symptoms. Many recognized at that point the valuable contribution of the physical therapy vestibular evaluation in achieving accurate diagnoses in these patients. Another breakthrough came when she was asked to present at a morbidity and mortality case conference. In this case (Case 4), the patient was initially misdiagnosed by physicians as having BPPV but, because of Dana’s attention to relevant history and symptoms, was correctly diagnosed with a stroke due to vertebral artery dissection.

Over the past few years, the nature of the discourse and interaction between Dana (along with her vestibular physical therapy team) and the treating physicians has changed substantially. A number of physicians have begun to rely on input from the physical therapy vestibular assessment more proactively, rather than waiting for the therapists to retroactively notify them that their medical diagnosis might be incorrect [e.g. by requesting consultation to “evaluate & treat” rather than requesting “PT for Epley” (i.e. a specific treatment maneuver for BPPV)]. Some physicians have even allowed Dana to educate them at the bedside in vestibular clinical skills, and have begun to incorporate vestibular exam skills into practice when admitting patients with vertigo and dizziness. One such physician reported that she was able to correctly identify an abnormal central (neurological) eye sign finding in a patient with a negative brain MRI. The physician, realizing that the exam indicated central vestibular pathology despite the negative MRI, ordered an MRA, which showed vertebral artery dissection. The physician indicated that prior to being educated by Dana in how to execute the HINTS exam, this would have been a patient whose negative MRI and symptomatology (vague lightheadedness, headache), would have led her to diagnose a benign condition such as migraine or inner ear disease, preventing her from seeking out more dangerous causes.

Over several years, Dana has been able to successfully build trusting relationships with many physician colleagues, who now routinely consider and use her clinical findings to inform subsequent diagnostic or management decisions. Some of the changes Dana has noted in her clinical practice setting are shown in Table 2.

Table 2:

Sociocultural changes and improved patient outcomes noted over time through interaction between an AHP (vestibular PT) and medical colleagues around diagnosis of patients with dizziness.


The role of vestibular PTs in diagnosis of dizziness and vertigo

In this case study, we have described the evolving role of an AHP (a vestibular PT) in diagnosis of a single problem (dizziness/vertigo) at a single-center. This case study reinforces and illustrates three domain-specific points that have been made previously in the literature: (1) misdiagnosis of dizziness by frontline physicians is a common problem [14, 15]; (2) many vestibular physical (or occupational) therapists are highly experienced in this domain [24] (often more so than generalist or even specialist physicians), publishing articles [25, 26] and teaching courses [27] almost identical to those for physicians specializing in dizziness or vertigo; (3) vestibular PTs must currently play a ‘shadow’ role in diagnosis, because of both scope-of-practice legal constraints and related sociocultural barriers [28]. The importance of these issues are underscored by the high frequency of the problem (>12 million doctor visits per year in the US [6, 7]), the dearth of subspecialty physicians in the US focused on diagnosing vestibular disorders (est. <250), and the greater numbers of PTs with relevant sub-discipline training (est. >4000). These issues point to the need for a dedicated effort to deliberately engage vestibular PTs as part of a team diagnostic process in dizziness and vertigo.

Historically, physical therapy practice acts in most states have expressly prohibited medical diagnosis. Though most PTs strive to avoid frank medical diagnosis, some find themselves in the position of providing vital information that influences diagnosis. Many PTs have developed strong physical examination and interview skills, coupled with high levels of anatomy and physiology knowledge, in their chosen areas of expertise. In many cases, PTs are able to recognize when clinical findings and history are (or are not) consistent with the physician’s initial medical diagnosis. Effective communication and teamwork between PTs and medical practitioners in these cases may help to increase the likelihood of accurate diagnosis, and subsequently, appropriate treatment interventions. A ‘team diagnosis’ approach can be very effective if the physician(s) or mid-level practitioner(s) involved in the patient’s care ascribe to a problem-solving model that includes physical therapy evaluation and input from other AHPs, as illustrated in this case study.

The role of all AHPs in diagnosis, more generally

These domain-specific points described here may generalize to other clinical circumstances, in which AHPs, by virtue of their specialized training and roles in assessing patient function, are well-equipped to diagnose certain symptoms or conditions (sometimes even more so than the physicians legally responsible for diagnosis). Other examples include the following: (1) a speech therapist’s role in diagnosing uncommon causes of dysphonia, such as myasthenia gravis [29]; (2) an audiologist’s role in diagnosing the underlying cause of tinnitus [30]; and (3) a nurse’s role in risk assessment and early diagnosis of venous thromboembolism [31]. Unfortunately, in our experience, while AHPs are now often included in treatment planning, it is relatively rare in clinical practice to see physicians willing to routinely engage AHPs in differential diagnostic discussions or decisions regarding further diagnostic testing.

In countering our contention of generalization beyond dizziness, some might claim that diagnosis of dizziness and vertigo is truly a special case. Diagnosis of dizziness and vertigo is an acknowledged problem for frontline physicians around the world, who have rated the issue of when to obtain neuroimaging for patients looking for serious neurologic causes a top priority for development of clinical decision rules [32]. Numerous studies have identified knowledge gaps [9, 10, 33], evidence-practice gaps [11, 13, 14], frequent diagnostic errors [12, 34, 35], and poor patient outcomes, such as missed strokes [3638]. By contrast, vestibular PTs are extensively trained in these topics [28], not generally covered in medical school or residency. However, dizziness is not unique in this regard. For example, similar issues have been identified for diagnosis of visual symptoms, including recognition of critical findings in the optic fundus, such as papilledema [39]. This is a skill not well taught (or learned) in medical school [40], and that carries forward to critical missed diagnoses in frontline clinical practice settings, such as the ED [39]. By contrast, optometrists are extensively trained in recognition of papilledema and differentiation of mimics [41].

Recommendations for “transdisciplinary team diagnosis”

The purpose of this manuscript is not to recommend that we supplant physician diagnoses with AHP diagnoses (or even that we specifically supplant physician diagnoses of dizziness with vestibular PT diagnoses of dizziness), but to highlight that barriers to effective “team diagnosis” (Table 3) are important patient safety risks. In therapeutic domains, communication and teamwork have been identified as critical patient safety factors [42]. Studies have recently begun to appear that demonstrate benefits of teamwork for diagnostic safety [43]. Some advantages of engaging AHPs in the diagnostic process can be found in Table 3.

Table 3:

Primary barriers to and advantages of engaging AHPs in the diagnostic process.

There is a rich tradition of thinking of diagnosis as largely a solo activity of the master physician clinician (e.g. the American TV show “House”), but, as articulated by Don Berwick, former president of the Institute for Healthcare Improvement, “Genius diagnosticians make great stories, but they don’t make great health care. The idea is to make accuracy reliable, not heroic” [44]. And it is likely that at least some portion of that reliability will derive from leveraging the whole team (including patients [45]) and effective sharing of information and knowledge to improve accuracy of diagnosis. While “multidisciplinary” teams have been engaged in cancer diagnosis for decades, these teams are primarily composed of different physician specialties [46]. Interdisciplinary (rather than multispecialty) teams that engage AHPs as partners in diagnosis are uncommon, in our experience. Truly transdisciplinary [47] (Table 4) team diagnosis, which creates a unity of intellectual frameworks beyond the disciplinary perspectives, is likely very rare in current clinical practice.

Table 4:

Definitions of key terms related to teamwork, listed from least to most collaborative [47].

There are obviously important legal scope-of-practice barriers to full integration of AHPs in clinical diagnosis. Many AHPs are prohibited by law from officially rendering medical diagnoses, or constrained to using only a narrowly constructed diagnostic framework. It is unrealistic to imagine these legal regulations will change quickly (if at all), but this is probably not necessary for effective team diagnosis, as there is no prohibition on AHPs sharing opinions with physicians. Instead, what is critical to overcome are logistical and sociocultural barriers to effective team diagnosis. Specifically, (1) AHPs should be engaged early and deliberately in clinical situations where their diagnostic expertise could benefit the patient; (2) methods or venues to effectively communicate for the purpose of true transdisciplinary “team diagnosis” should be developed; and (3) sociocultural change should be deliberately cultivated.

This third point, strongly recommended in the NAM report on Improving Diagnosis in Healthcare [5], bears some emphasis, in that the culture change required is for both physicians and AHPs. Physicians will need to initiate a respectful dialog with AHPs to solicit their input regarding diagnosis, and AHPs will need to move beyond fears of overstepping their “station” by sharing diagnostic information with physicians. For example, it is notable that articles written for PTs discussing diagnosis often assiduously emphasize that diagnosis is outside the PT’s scope of practice… while at the same time describing how to diagnose and treat benign positional vertigo and other vestibular disorders [48]. The international consensus curriculum for vestibular PTs is no exception, explaining that therapists should “evaluate, treat, and manage care of patients with vestibular disorders” and be educated regarding “the process of differential diagnosis based on the history, analysis of eye movements, evaluation of sensory impairment… and other signs and symptoms, although actually making a diagnosis is outside the scope of practice…” [28]. Culture change around diagnosis will not be easy, but, fortunately, there are prior successful models of how it may be accomplished. Table 5 draws some explicit parallels between team therapy and team diagnosis, using specific examples [49, 50].

Table 5:

Parallels between proven culture change for therapeutic safety and those anticipated in the future for diagnostic safety, using specific exemplars.

Finally, as a case study, these findings are hypothesis generating, and suggest there may be value in more formally studying the role of AHPs in the diagnostic process. Only a handful of prior studies have looked at the impact of personnel changes on diagnostic safety, representing the least well-studied class of interventions to reduce diagnostic error [51]. To our knowledge, only one research study has directly examined the role of AHPs in diagnosis (a single-center randomized trial showing no difference in emergency nurse practitioners’ accuracy to that of junior doctors) [52]. Future research should specifically study the impact of engaging vestibular PTs in diagnosing dizziness and vertigo, and, more generally, the impact of engaging AHPs in diagnosis across a wide range of conditions.


This was a qualitative, self-report study from a single care provider, dealing with a single clinical problem, at a single institution. The case sample is small, and may not be representative. Results may not generalize to other providers, problems, or settings.


High-quality diagnosis should be considered a team sport. Those who fail to treat it as such do so at their own peril, with potentially devastating consequences for their patients. In the specific case of dizziness and vertigo, it should be routine practice to engage knowledgeable vestibular PTs in the diagnostic process, especially when appropriate medical subspecialty expertise is not immediately available (which is most of the time).

Barriers to AHP engagement in “team diagnosis” include sociocultural norms that establish medical diagnosis as something reserved only for physicians. Drawing attention to the valuable diagnostic contributions of AHPs may help facilitate cultural change. We must break down sociocultural barriers to engaging AHPs in team diagnosis, in order to help minimize the risks of physician misdiagnosis. Engagement of physician champions may facilitate change. Future studies should measure diagnostic safety culture and implement proven strategies to breakdown sociocultural barriers that inhibit effective teamwork and transdisciplinary diagnosis. The impact of AHPs on diagnostic accuracy should be studied across a wide range of problems.


  • 1.

    Newman-Toker DE, Pronovost PJ. Diagnostic errors – the next frontier for patient safety. J Am Med Assoc 2009;301:1060–2. CrossrefGoogle Scholar

  • 2.

    Saber Tehrani AS, Lee H, Mathews SC, Shore A, Makary MA, Pronovost PJ, et al. 25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the national practitioner data bank. Br Med J Qual Saf 2013;22:672–80.CrossrefGoogle Scholar

  • 3.

    Singh H, Meyer AN, Thomas EJ. The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. Br Med J Qual Saf 2014;23:727–31.CrossrefGoogle Scholar

  • 4.

    Newman-Toker DE. Diagnostic value: the economics of high-quality diagnosis and a value-based perspective on diagnostic innovation. Paper presented at: Modern Healthcare Annual Patient Safety & Quality Virtual Conference, 2015. Google Scholar

  • 5.

    Improving Diagnosis in Healthcare. 2015; Available at: http://iom.nationalacademies.org/Reports/2015/Improving-Diagnosis-in-Healthcare.aspx. Accessed April 25, 2016. 

  • 6.

    Sloane PD. Dizziness in primary care. Results from the National Ambulatory Medical Care Survey. J.Fam Pract 1989;29:33–8. PubMedGoogle Scholar

  • 7.

    Saber Tehrani AS, Coughlan D, Hsieh YH, Mantokoudis G, Korley FK, Kerber KA, et al. Rising annual costs of dizziness presentations to U.S. emergency departments. Acad Emerg Med 2013;20:689–96. PubMedCrossrefGoogle Scholar

  • 8.

    Newman-Toker DE. Charted records of dizzy patients suggest emergency physicians emphasize symptom quality in diagnostic assessment. Ann Emerg Med 2007;50:204–5. PubMedCrossrefGoogle Scholar

  • 9.

    Stanton VA, Hsieh YH, Camargo CA, Jr., Edlow JA, Lovett PB, Goldstein JN, et al. Overreliance on symptom quality in diagnosing dizziness: results of a multicenter survey of emergency physicians. Mayo Clin Proc 2007;82: 1319–28. PubMedCrossrefGoogle Scholar

  • 10.

    Newman-Toker DE, Stanton VA, Hsieh YH, Rothman RE. Frontline providers harbor misconceptions about the bedside evaluation of dizzy patients. Acta Otolaryngol 2008;128:601–4. PubMedCrossrefGoogle Scholar

  • 11.

    Newman-Toker DE, Camargo CA, Jr., Hsieh YH, Pelletier AJ, Edlow JA. Disconnect between charted vestibular diagnoses and emergency department management decisions: a cross-sectional analysis from a nationally representative sample. Acad Emerg Med 2009;16:970–7. PubMedCrossrefGoogle Scholar

  • 12.

    Kerber KA, Morgenstern LB, Meurer WJ, McLaughlin T, Hall PA, Forman J, et al. Nystagmus assessments documented by emergency physicians in acute dizziness presentations: a target for decision support? Acad Emerg Med 2011;18:619–26. PubMedCrossrefGoogle Scholar

  • 13.

    Kerber KA, Burke JF, Skolarus LE, Meurer WJ, Callaghan BC, Brown DL, et al. Use of BPPV processes in emergency department dizziness presentations: a population-based study. Otolaryngol Head Neck Surg 2013;148:425–30. PubMedCrossrefGoogle Scholar

  • 14.

    Kerber KA, Newman-Toker DE. Misdiagnosing dizzy patients: common pitfalls in clinical practice. Neurol Clin 2015;33:565–75. CrossrefPubMedGoogle Scholar

  • 15.

    Newman-Toker DE. Missed stroke in acute vertigo and dizziness: it is time for action, not debate. Ann Neurol 2016;79:27–31. CrossrefPubMedGoogle Scholar

  • 16.

    Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke 2009;40:3504–10. CrossrefPubMedGoogle Scholar

  • 17.

    Tarnutzer AA, Berkowitz AL, Robinson KA, Hsieh YH, Newman-Toker DE. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. Can Med Assoc J 2011;183:E571–592. CrossrefGoogle Scholar

  • 18.

    Newman-Toker DE, Kerber KA, Hsieh YH, Pula JH, Omron R, Saber Tehrani AS, et al. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Acad Emerg Med 2013;20:986–96.CrossrefPubMedGoogle Scholar

  • 19.

    Newman-Toker DE, Kattah JC. HINTS to identify stroke in ED patients with dizziness [In Reply] Acad Emerg Med 2014;21:348–9.Google Scholar

  • 20.

    Newman-Toker DE, Curthoys IS, Halmagyi GM. Diagnosing stroke in acute vertigo: the HINTS family of eye movement tests and the future of the “Eye ECG”. Semin Neurol 2015;35:506–21. CrossrefPubMedGoogle Scholar

  • 21.

    Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the quality standards subcommittee of the american academy of neurology. Neurology 2008;70:2067–74. PubMedCrossrefGoogle Scholar

  • 22.

    Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 2008;139 (5 Suppl 4):S47–81. PubMedCrossrefGoogle Scholar

  • 23.

    Newman-Toker DE, Edlow JA. TiTrATE: a novel, evidence-based approach to diagnosing acute dizziness and vertigo. Neurol Clin 2015;33:577–99. CrossrefPubMedGoogle Scholar

  • 24.

    Cohen HS, Gottshall KR, Graziano M, Malmstrom EM, Sharpe MH. International survey of vestibular rehabilitation therapists by the barany society ad hoc committee on vestibular rehabilitation therapy. J Vestib Res 2009;19:15–20. PubMedGoogle Scholar

  • 25.

    Herdman SJ. Advances in the treatment of vestibular disorders. Phys Ther 1997;77:602–18. CrossrefPubMedGoogle Scholar

  • 26.

    Cohen HS. Side-lying as an alternative to the dix-hallpike test of the posterior canal. Otol Neurotol 2004;25:130–4. CrossrefPubMedGoogle Scholar

  • 27.

    Professional Education: Conferences & Training. 2015; Available at: http://vestibular.org/resources-professionals/build-your-practice. Website. Accessed April 25, 2016. 

  • 28.

    Cohen HS, Gottshall KR, Graziano M, Malmstrom EM, Sharpe MH, Whitney SL. International guidelines for education in vestibular rehabilitation therapy. J Vestib Res 2011;21:243–50. PubMedGoogle Scholar

  • 29.

    Nemr NK, Simoes-Zenari M, Ferreira TS, Fernandes HR, Mansur LL. Dysphonia as the primary complaint in a case of myasthenia gravis: diagnosis and speech therapy. Codas 2013;25:297–300. Google Scholar

  • 30.

    Audiologic Guidelines for the Diagnosis & Management of Tinnitus Patients. 2000; Available at: http://www.audiology.org/publications-resources/document-library/audiologic-guidelines-diagnosis-management-tinnitus-patients. Accessed April 25, 2016. 

  • 31.

    Morrison R. Venous thromboembolism: scope of the problem and the nurse’s role in risk assessment and prevention. J Vasc Nurs 2006;24:82–90. CrossrefPubMedGoogle Scholar

  • 32.

    Eagles D, Stiell IG, Clement CM, Brehaut J, Taljaard M, Kelly AM, et al. International survey of emergency physicians’ awareness and use of the Canadian cervical-spine rule and the Canadian computed tomography head rule. Acad Emerg Med 2008;15:1256–61. PubMedCrossrefGoogle Scholar

  • 33.

    Bashir K, Qotb MA, Alkahky S, Fathi AM, Mohamed MA, Cameron PA. Are emergency physicians and paramedics providing canalith repositioning manoeuvre for benign paroxysmal positional vertigo? Emerg Med Australas 2015;27:179–80. CrossrefPubMedGoogle Scholar

  • 34.

    Royl G, Ploner CJ, Leithner C. Dizziness in the emergency room: diagnoses and misdiagnoses. European neurology 2011;66:256–63. PubMedCrossrefGoogle Scholar

  • 35.

    Geser R, Straumann D. Referral and final diagnoses of patients assessed in an academic vertigo center. Front Neurol 2012;3:169. Google Scholar

  • 36.

    Kerber KA, Brown DL, Lisabeth LD, Smith MA, Morgenstern LB. Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study. Stroke 2006;37:2484–7. CrossrefPubMedGoogle Scholar

  • 37.

    Savitz SI, Caplan LR, Edlow JA. Pitfalls in the diagnosis of cerebellar infarction. Acad Emerg Med 2007;14:63–8.CrossrefGoogle Scholar

  • 38.

    Newman-Toker DE, Moy E, Valente E, Coffey R, Hines A. Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample. Diagnosis 2014;1:155–66. Google Scholar

  • 39.

    Bruce BB, Lamirel C, Wright DW, Ward A, Heilpern KL, Biousse V, et al. Nonmydriatic ocular fundus photography in the emergency department. N Engl J Med 2011;364:387–9. CrossrefPubMedGoogle Scholar

  • 40.

    Benbassat J, Polak BC, Javitt JC. Objectives of teaching direct ophthalmoscopy to medical students. Acta Ophthalmol 2012;90:503–7. PubMedCrossrefGoogle Scholar

  • 41.

    Kreda SH. Diagnosis and management of optic disc elevation: making the right diagnosis can help avoid needless tests while saving lives and vision. Optometric Management 2009. Available at: http://www.optometricmanagement.com/articleviewer.aspx?articleID=103086. Accessed April 25, 2016. 

  • 42.

    Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaesthesiol Scand 2009;53:143–51. PubMedCrossrefGoogle Scholar

  • 43.

    Hautz WE, Kammer JE, Schauber SK, Spies CD, Gaissmaier W. Diagnostic performance by medical students working individually or in teams. J Am Med Assoc 2015;313:303–4. CrossrefGoogle Scholar

  • 44.

    Schiff GD, Kim S, Abrams R, Cosby K, Lambert B, Elstein AS, et al. Diagnosing diagnosis errors: lessons from a multi-institutional collaborative project. Agency for Healthcare Research and Quality (AHRQ); 2005:255–78. Google Scholar

  • 45.

    McDonald KM. The diagnostic field’s players and interactions: from the inside out. Diagnosis 2014;1:55–8. Google Scholar

  • 46.

    Yassa L, Cibas ES, Benson CB, Frates MC, Doubilet PM, Gawande AA, et al. Long-term assessment of a multidisciplinary approach to thyroid nodule diagnostic evaluation. Cancer 2007;111:508–16. PubMedCrossrefGoogle Scholar

  • 47.

    Stember M. Advancing the social sciences through the interdisciplinary enterprise. Social Sci J 1991;28:1–14. CrossrefGoogle Scholar

  • 48.

    Herdman SJ. Treatment of benign paroxysmal positional vertigo. Phys Ther 1990;70:381–8. PubMedCrossrefGoogle Scholar

  • 49.

    Romig M, Goeschel C, Pronovost P, Berenholtz SM. Integrating CUSP and TRIP to improve patient safety. Hosp Pract (1995) 2010;38:114–21. CrossrefPubMedGoogle Scholar

  • 50.

    Dixon-Woods M, Bosk CL, Aveling EL, Goeschel CA, Pronovost PJ. Explaining Michigan: developing an ex post theory of a quality improvement program. Milbank Q 2011;89:167–205. CrossrefPubMedGoogle Scholar

  • 51.

    McDonald KM, Matesic B, Contopoulos-Ioannidis DG, Lonhart J, Schmidt E, Pineda N, et al. Patient safety strategies targeted at diagnostic errors: a systematic review. Ann Int Med 2013;158(5 Pt 2):381–9. CrossrefGoogle Scholar

  • 52.

    Sakr M, Angus J, Perrin J, Nixon C, Nicholl J, Wardrope J. Care of minor injuries by emergency nurse practitioners or junior doctors: a randomised controlled trial. Lancet 1999;354:1321–6. PubMedCrossrefGoogle Scholar

Supplemental Material:

The online version of this article (DOI: 10.1515/dx-2016-0009) offers supplementary material, available to authorized users.

About the article

Corresponding author: David E. Newman-Toker, MD, PhD, Associate Professor, Department of Neurology and Otolaryngology, The Johns Hopkins University School of Medicine, CRB-II, Room 2M-03 North 1550 Orleans Street, Baltimore, MD 21231, USA, Phone: 443-287-9593, Fax: 410-502-7869

Received: 2016-03-06

Accepted: 2016-04-27

Published Online: 2016-05-31

Published in Print: 2016-06-01

Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission. They have no financial conflicts of interest. The corresponding author (David E. Newman-Toker) had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The corresponding author also had final responsibility for the decision to submit for publication. No medical writer or editor was involved in the creation of this manuscript.

Conflict of interest statement: No conflicts of interest. None of the authors have any financial or personal relationships with other people or organizations that could inappropriately influence (bias) their work.

Research funding: Preparation of this manuscript was partly supported by a grant from the National Institutes of Health via the National Institute on Deafness and Other Communication Disorders (1 U01 DC013778-01A1). The funding agency was not involved in the writing, approval, or decision to publish this manuscript.

Employment or leadership: None declared.

Honorarium: None declared.

Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.

Citation Information: Diagnosis, Volume 3, Issue 2, Pages 49–59, ISSN (Online) 2194-802X, ISSN (Print) 2194-8011, DOI: https://doi.org/10.1515/dx-2016-0009.

Export Citation

©2016 by De Gruyter.Get Permission

Supplementary Article Materials

Citing Articles

Here you can find all Crossref-listed publications in which this article is cited. If you would like to receive automatic email messages as soon as this article is cited in other publications, simply activate the “Citation Alert” on the top of this page.

Priya N. Bhat, John M. Costello, Ranjit Aiyagari, Paul J. Sharek, Claudia A. Algaze, Mjaye L. Mazwi, Stephen J. Roth, and Andrew Y. Shin
Cardiology in the Young, 2018, Volume 28, Number 05, Page 675
Kelly T. Gleason, Patricia M. Davidson, Elizabeth K. Tanner, Diana Baptiste, Cynda Rushton, Jennifer Day, Melinda Sawyer, Deborah Baker, Lori Paine, Cheryl R. Dennison Himmelfarb, and David E. Newman-Toker
Diagnosis, 2017, Volume 0, Number 0

Comments (0)

Please log in or register to comment.
Log in