Symptoms and selection bias: the influence of selection towards specialist care on the relationship between symptoms and diagnoses.

Observations with respect to the relationship between symptoms and diseases can seriously be biased by selection phenomena. This selection may occur from the general population, via consultation behavior, diagnostic and therapeutic activities of the general practitioner, and by referral. Relationships may be suggested and reproduced even if they do not exist in unselected populations, as a product of diagnostic routines. Correction for selection bias can only be achieved by choosing proper comparison groups. While this can be done in a general practice setting, this is almost impossible after referral, as is demonstrated in this paper. Surprisingly, the most unbiased estimation of the relationship between symptoms and diseases after referral can be made from patient groups that are referred for reason unrelated to the disease under study. Definitive answers for the general practitioner can only be provided by prospective studies from a primary care setting. In the meantime, however, biased relationships can be maintained by teaching knowledge derived from a specialist experience.