Lack of time, knowledge or just sloppy thinking?

Jason Maude Jason.Maude at ISABELHEALTHCARE.COM
Thu May 2 08:19:38 UTC 2013


I initially saw my GP (very experienced and senior partner in the practice) who was certainly not rushed as he even asked me about some other things I had seen him with before. The x-ray was carried out at the small local hospital that was attached to the practice. There was no queue to get the x-ray done so I don't believe that the radiologist was rushed. It was then looked at again by a couple of nurse practitioners, all in the calm of a sleepy English country town hospital!

This is why I started to conclude that lack of time could often be an excuse rather than a legitimate explanation. I also blamed myself for too easily accepting what seemed a plausible diagnosis. I should have asked "what else could it be" and acted as the trigger for more thinking. The whole episode showed me what an easy trap it is to fall into.

So do we either accept this as the norm and say that nothing can be done (not enough time etc)- in other words there will be an inbuilt industry dx error of 10-20% - or is there a way we can force change. My view, reinforced by this episode, remains that the differential (or say 3 diagnoses) must be recorded in the medical notes at the time of the consultation.


From: Karen Cosby <kcosby40 at gmail.com<mailto:kcosby40 at gmail.com>>
Date: Thursday, 2 May 2013 01:57
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>>
Subject: Re: Lack of time, knowledge or just sloppy thinking?

I wonder if your assumption that none of the doctors looked rushed might be a misperception. As an Emergency Medicine physician I am surprised at how many times people interrupt me. Sometimes even the interruptions are interrupted. I have noted a number of times (even daily) when I am aware that 3 or more people are speaking to me at once, all seemingly unaware of each other.  At the same time, buzzers and alarms may sound, and my pager or cell phone may go off. This puzzled me for a long time (are people really that rude, I thought!?), then I realized that others don't see it because sometimes they are just interrupting my thought process.  They don't know that I am mentally solving a puzzle, considering a differential diagnosis, viewing an x-ray and processing many things I need to take in.  Many times my thoughts are short-circuited before I have processed the information.  No wonder we can't see things right in front of us.  A check list might force us to slow down to complete the process, but then we might not recognize the emergency in the next bay if we are too focused on a list.  I recently watched a colleague totally ignore a crashing patient because she was fixated on completing an electronic note.  Yikes!


On Wed, May 1, 2013 at 6:22 AM, Jason Maude <Jason.Maude at isabelhealthcare.com<mailto:Jason.Maude at isabelhealthcare.com>> wrote:
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:%2B44%201428%20644886>
Tel: +1 703 879 1890<tel:%2B1%20703%20879%201890>
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
McMaster University
1200 Main St. W.
Hamilton ON L8N3Z5, Canada

norman at mcmaster.ca<mailto:norman at mcmaster.ca>
(905) 525-9140, ext.22119<tel:%28905%29%20525-9140%2C%20ext.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<tel:%28301%29%20427-1331>
fax:        (301) 427-1341<tel:%28301%29%20427-1341>

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<tel:%28205%29975%E2%80%948219>
Fax:       (205)975-6608<tel:%28205%29975-6608>
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
McMaster University
1200 Main St. W.
Hamilton ON L8N3Z5, Canada

norman at mcmaster.ca<mailto:norman at mcmaster.ca>
(905) 525-9140, ext.22119<tel:%28905%29%20525-9140%2C%20ext.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:%2B44%201428%20644886>
Tel: +1 703 879 1890<tel:%2B1%20703%20879%201890>
www.isabelhealthcare.com<http://www.isabelhealthcare.com/>


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