Lack of time, knowledge or just sloppy thinking?

Robert L Wears, MD, MS, PhD wears at UFL.EDU
Thu May 2 03:33:04 UTC 2013


My take on checklists in general is that they are a consequence rather than a cause.

bob


On 1 May 2013 at 13:33, Michael.H.Kanter at KP.ORG wrote:

Date sent:	Wed, 1 May 2013 13:33:58 -0700
Send reply to:	Society to Improve Diagnosis in Medicine
             	<IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>,
       	Michael.H.Kanter at KP.ORG
From:	Michael.H.Kanter at KP.ORG
Subject:	Re: Lack of time, knowledge or just sloppy thinking?
To:	IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

> 
> In my view it is not the checklists per se but also the culture that
> accompanies the checklist that creates safety and reliability. 
> Checklists alone do not add all that much value
> 
> 
> 
> Sent with Good (www.good.com)
> 
> 
> 
> -------- Original Message --------
> 
> From :      Alan Morris <Alan.Morris at IMAIL.ORG>
> To :		 IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Cc :
> Sent on : 05/01 07:07:38 AM PDT
> Subject : Re: Lack of time, knowledge or just sloppy thinking?
> 
> 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>
> Date:  Wednesday, May 1, 2013 7:54 AM
> To:  'Society to Improve Diagnosis in Medicine' <
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, "Alan H. Morris, MD" <
> 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
> 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 & LungCenter - 6th Floor
> 
> IntermountainMedicalCenter
> 
> 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
> 
> e-mail: alanhmorris at gmail.com
> 
> 
> 
> From: Jason Maude <Jason.Maude at ISABELHEALTHCARE.COM>
> Reply-To: Society to Improve Diagnosis in Medicine <
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Jason Maude <
> Jason.Maude at ISABELHEALTHCARE.COM>
> Date: Wednesday, May 1, 2013 5:22 AM
> To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <
> 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-diagnosi
> s-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
> 
> 
> 
> From: robert bell <rmsbell at ESEDONA.NET>
> Reply-To: Society to Improve Diagnosis in Medicine <
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, robert bell
> <rmsbell at ESEDONA.NET> Date: Tuesday, 30 April 2013 19:07 To:
> "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <
> 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. 2002 Oct;77(10 Suppl):S1-6.
> 
> The aging physician: changes in cognitive processing and their
> impact on medical practice.
> 
> Eva KW.
> 
> 
> 
> 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
> 
> 
> 
> MDCL 3519
> 
> McMasterUniversity
> 
> 1200 Main St. W.
> 
> Hamilton ON L8N3Z5, Canada
> 
> 
> 
> 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, MD20850
> 
> 
> 
> e-mail:  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
> 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 Alabamaat Birmingham
> 
> 1675 University Blvd. #534
> 
> Birmingham, AL35294
> 
> Phone: (205)975-8219
> 
> Fax:       (205)975-6608
> 
> Email:   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
> 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
> 
> 
> 
> MDCL 3519
> 
> McMasterUniversity
> 
> 1200 Main St. W.
> 
> Hamilton ON L8N3Z5, Canada
> 
> 
> 
> 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
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
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> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair,
> Society for Improving Diagnosis in Medicine
> 
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> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair,
> Society for Improving Diagnosis in Medicine
> 
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
> 
> 
> Save the date: Diagnostic Error in Medicine 2013. September 22-25,
> 2013 in Chicago, IL. http://www.dem2013.org
> 
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> 
> 
> 
> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair,
> Society for Improving Diagnosis in Medicine
> 
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Robert L Wears, MD, MS, PhD
University of Florida  	Imperial College London
wears at ufl.edu		r.wears at imperial.ac.uk
1-904-244-4405 (ass't)  	+44 (0)791 015 2219
Attention ... is only a momentary affair.
                              --W James










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