Lack of time, knowledge or just sloppy thinking?

Alan Morris Alan.Morris at IMAIL.ORG
Wed May 1 14:07:38 UTC 2013


If we did this to pilots, no one would fly.
Paradoxically, we have tools to address this – but virtually no support of interest from funding agencies to pursue development.
Have  a nice day.

Alan H. Morris, M.D.


From: "Dr.Will" <dr.will at fuse.net<mailto:dr.will at fuse.net>>
Date: Wednesday, May 1, 2013 7:54 AM
To: 'Society to Improve Diagnosis in Medicine' <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, "Alan H. Morris, MD" <alan.morris at imail.org<mailto:alan.morris at imail.org>>
Subject: RE: Lack of time, knowledge or just sloppy thinking?

Yes and EMR data entry requirements have exceeded human capability to provide good clinical care (and both eyes and physical contact on patient) in the compressed time allotment by insurance payment and hospital owned productivity requirements. No wonder there are errors in DX and Outcomes.
If we did this to pilots, there would be more errors, as well. My brother is a retired pilot.
Will Sawyer, MD

________________________________
From: Alan Morris [mailto:Alan.Morris at IMAIL.ORG]
Sent: Wednesday, May 01, 2013 9:26 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: Lack of time, knowledge or just sloppy thinking?

My assessment is that human think is "sloppy",  by which I mean more attuned to system 1 than system 2 cogitation (re Khanneman, Thinking Fast and Slow).  This is why, I believe, pilots and the FAA have for so long relied on checklists.  It reflects their implicit appreciation of human thought limitations.
Have  a nice day.

Alan H. Morris, M.D.
Professor of Medicine
Adjunct Prof. of Medical Informatics
University of Utah

Director of Research
Director Urban Central Region Blood Gas and Pulmonary Laboratories
Pulmonary/Critical Care Division
SorensonHeart & Lung Center - 6th Floor
IntermountainMedical Center
5121 South Cottonwood Street
Murray, Utah  84157-7000, USA

Office Phone: 801-507-4603
Mobile Phone: 801-718-1283
Fax: 801-507-4699
e-mail: alan.morris at imail.org<mailto:alan.morris at imail.org>
e-mail: alanhmorris at gmail.com<mailto:alanhmorris at gmail.com>

From: Jason Maude <Jason.Maude at ISABELHEALTHCARE.COM<mailto:Jason.Maude at ISABELHEALTHCARE.COM>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Jason Maude <Jason.Maude at ISABELHEALTHCARE.COM<mailto:Jason.Maude at ISABELHEALTHCARE.COM>>
Date: Wednesday, May 1, 2013 5:22 AM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: Lack of time, knowledge or just sloppy thinking?

As another research focus, I think it would be useful to try and look at dx decision errors and analyse whether they were due to lack of time, lack of knowledge or just sloppy thinking. This again would have a big influence on possible solutions.

I experienced my own, minor, misdiagnosis a few weeks ago which I recounted in a blog: http://info.isabelhealthcare.com/blog/bid/177313/Differential-diagnosis-the-crucial-trigger-for-thinking-better

In short, I damaged my hand and got an initial diagnosis (from my GP) of a fractured 4th metacarpal which was confirmed on x-ray. A routine review of the x-ray 2 days later (by a senior radiologist) showed that I had also dislocated my 5th carpometacarpal joint which was much more serious and needed an immediate operation. Hopefully there will be no long term damage. The ortho that carried out the operation said that the dislocation "stuck out like a sore thumb" on the x-ray!

None of the clinicians I saw was rushed so this simple mistake couldn't have been due to lack of time and I concluded was either due to lack of knowledge or, more likely, sloppy thinking.

Were Rob's errors below due to lack of time or sloppy thinking? If time was not the issue then the solution has to be a practical trigger to step back and think more methodically. At what point does lack of time move from being a reasonable explanation to just an excuse for sloppy thinking?



Jason Maude
Founder and CEO Isabel Healthcare
Tel: +44 1428 644886
Tel: +1 703 879 1890
www.isabelhealthcare.com<http://www.isabelhealthcare.com/>

From: robert bell <rmsbell at ESEDONA.NET<mailto:rmsbell at ESEDONA.NET>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, robert bell <rmsbell at ESEDONA.NET<mailto:rmsbell at ESEDONA.NET>>
Date: Tuesday, 30 April 2013 19:07
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: DX error by age groups

I wonder if there are any fairly accurate surrogates for medical errors including diagnostic.

We all forget something everyday.

For two days I collected all the ones that annoyed me, were somewhat inconvenient.

e.g.
Getting into the car in the garage and forgetting the letter to be mailed.
Driving off and forgetting to check that the garage door is down.

If I remember correctly I had 7 one day and 5 the next!!

Try it.

Beat me and then I will then divulge my age?!

Rob Bell



On Apr 30, 2013, at 10:48 AM, Lorri Zipperer wrote:


From: Geoff Norman [mailto:norman at mcmaster.ca]
Sent: Tuesday, April 30, 2013 11:45 AM
To: Society to Improve Diagnosis in Medicine; Henriksen, Kerm (AHRQ)
Subject: Re: DX error by age groups

To continue answering the question that wasn't asked, Kevin Eva wrote a review article for Academic Medicine on the aging physician:

Acad Med.<http://www.ncbi.nlm.nih.gov/pubmed/12377689> 2002 Oct;77(10 Suppl):S1-6.
The aging physician: changes in cognitive processing and their impact on medical practice.
Eva KW<http://www.ncbi.nlm.nih.gov/pubmed?term=Eva%20KW%5BAuthor%5D&cauthor=true&cauthor_uid=12377689>.

As to teaching / non-teaching latest Acad Med has an article on AMI survival rates, controlling for patient factors, and looking at community / minor teaching / major teaching. No significant differences.


Geoff

Geoff Norman
norman at mcmaster.ca<mailto:norman at mcmaster.ca>

MDCL 3519
McMasterUniversity
1200 Main St. W.
Hamilton ON L8N3Z5, Canada

norman at mcmaster.ca<mailto:norman at mcmaster.ca>
(905) 525-9140, ext.22119



On 2013-04-30, at 11:07 AM, Henriksen, Kerm (AHRQ) wrote:



Residency training is mentioned, so isn’t Geoff referring to practitioners?


Kerm Henriksen, PhD
Human Factors Advisor for Patient Safety
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850

e-mail:  Kerm.Henriksen at ahrq.hhs.gov<mailto:Kerm.Henriksen at ahrq.hhs.gov>
phone: (301) 427-1331
fax:        (301) 427-1341

From: Eta S Berner [mailto:eberner at UAB.EDU]
Sent: Tuesday, April 30, 2013 10:50 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: DX error by age groups

I thought you meant by age of the patient, like are there likely to be more errors in kids, in the elderly etc.

*********************************************
Eta S. Berner, Ed.D.
Professor, Health Informatics
Director, Center for Health Informatics for Patient Safety/Quality
Department of Health Services Administration
School of Health Professions
Professor, Department of Medical Education
School of Medicine
University of Alabama at Birmingham
1675 University Blvd. #534
Birmingham, AL 35294
Phone: (205)975—8219
Fax:       (205)975-6608
Email:   eberner at uab.edu<mailto:eberner at uab.edu>

From: Geoff Norman [mailto:norman at MCMASTER.CA]
Sent: Tuesday, April 30, 2013 9:35 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: DX error by age groups

I have been tracking exactly this question for some time.. I have located probably 15 studies that address the question. First of all, it's easy to show a strong positive relationship with residency training, which is not the case if you look at measures like adherence to guidelines, ABIM performance etc. But beyond residency it's more tricky.I have not summarized the data quantitatively as yet, but I think the best guess is that there is a small negative relation between age and dx error, typically around -0.1.  And many outliers. In one study we did with elite internists, the best performer was 65, and the worst performer was 65.

But a tantalizing possibility is that it may follow the "10,000" hour curve and be curvilinear, peaking at around 45. There's just not enough data to find this.


Geoff

Geoff Norman
norman at mcmaster.ca<mailto:norman at mcmaster.ca>

MDCL 3519
McMasterUniversity
1200 Main St. W.
Hamilton ON L8N3Z5, Canada

norman at mcmaster.ca<mailto:norman at mcmaster.ca>
(905) 525-9140, ext.22119

 On 2013-04-30, at 5:46 AM, Jason Maude wrote:
 Hi to the new group.
 Does anybody know of any studies that show dx error by age group?

Many thanks


Jason Maude
Founder and CEO Isabel Healthcare
Tel: +44 1428 644886
Tel: +1 703 879 1890
www.isabelhealthcare.com<http://www.isabelhealthcare.com/>


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To learn more about SIDM visit:
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Save the date: Diagnostic Error in Medicine 2013. September 22-25, 2013 in Chicago, IL.
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