Crowd Wisdom for Diagnosis?

Davis, Andrew [BSD] - MED adavis at MEDICINE.BSD.UCHICAGO.EDU
Wed Jul 17 18:17:54 UTC 2013


I think it's hard to be dogmatic, given that the value of crowd diagnosis in most cases almost certainly depends on a number of factors.


1)      The nature of symptoms, and where in the 'ecology of medical care' the patient is (see NEJM slide below).  A patient with a concern about possible tennis elbow vs. cervical radiculopathy is in a different place than someone who's seen multiple physicians for fever and 30# weight loss without getting a diagnosis. Patients are smart and there's a lot of informal self-referral to web sites, neighbors and family, GNC clerks, pharmacists, and alternative practitioners.

2)      Sometimes patients simply don't like the answer they've competently received, or perhaps how it was communicated - think, Cancer Treatment Centers of America.

3)      Whether there's a trusting relationship with a clinician who is skilled in supporting the patient in the face of uncertainty, one who provides the patient with a sense of respectful regard for the patient's experience, and who is aware of their limits and can ask for help from colleagues and specialists.

4)      Patient anxiety and somaticization, and the search by some patients for medical answers to more existential issues like aging, and problems at work and in relationships

The overall discussion pre-supposes that there IS a single unaddressed diagnosis, and that it will have an effective, safe, and affordable therapy.

For every "did they think about porphyria??" there'll be many more cases of irritable bowel, and a litany of added investigations of limited value, high cost to patient and society, and sometimes actual physical harm from the procedures so triggered.

I look forward to a USPSTF review of crowd diagnosis, weighing the competing benefits and harms  ;-)

Andy Davis, MD, MPH
University of Chicago

[cid:image002.png at 01CE82F0.0BA83CE0]

From: Peggy Zuckerman [mailto:peggyzuckerman at GMAIL.COM]
Sent: Wednesday, July 17, 2013 11:27 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: Crowd Wisdom for Diagnosis?

Dr. Zamir's suggestion that doctors who are puzzled by a diagnosis and turn to this or similar sites could solve some of the errors  that occur.  Frankly, I am more concerned about the doctor who has made a misdiagnosis, and has no idea that he has done so.

Thus the need for the patient to search out more input into the unresolved issue.  There is little information on the impact of misdiagnosis, but many in this community have personal experience with this.  Multiply that tenfold and you get a sense of the cost to our society.

A friend sums this up in the simple question that floats in the mind of every frustrated patient, "How do I know if my doctor knows what he is talking about?".

Peggy Z

On Wed, Jul 17, 2013 at 7:35 AM, Timothy Krohe <tkrohe1 at gmail.com<mailto:tkrohe1 at gmail.com>> wrote:

Agree with Dr Zamir the better utility of posting to physicians-only services .



While my goal is not to provide a plug,  this type of assistance happens regularly on sermo.com<http://sermo.com> .  In frequent posts,   a physician  describes a case,  requests help AND usually provides feedback to enhance learning. All posts are visible to all physicians, so there are glimpses of "how (other) doctors think".  Access is free to licensed physicians.  The website has MANY other humor/stress release/political/administrative postings as well so is not purely clinical and you need to sift for the clinically useful posts.



In the DoD, there is a worldwide teleconsult service that emails requests for help , often from the outlying combat or isolated bases. A large group of specialists/internists from the larger military hospitals have responsibility to respond quickly with comments/recommendations.   Very collegial and supportive for those docs/corpsmen/NPs/PAs providing care in isolated area. Access obviously limited to DoD.


I have enjoyed and learned (and I hope helped other MDs) from both systems.  No fees for the reqeuster in either.


TL Krohe MD General Internal Medicine





-----Original Message-----
From: Ehud Zamir [mailto:ezamir at UNIMELB.EDU.AU<mailto:ezamir at UNIMELB.EDU.AU>]
Sent: Tuesday, July 16, 2013 9:23 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: Crowd Wisdom for Diagnosis?



Interesting idea. However, one has to remember that in primary care, most patients with unresolved symptoms (after medical assessment) have no serious or significant underlying problem. Not sure anyone has ever counted them, but I think one may safely assume that a competent GP is often required to conclude, correctly, "I don't know what the reason for your chronic headache is, Mrs Smith, but I can tell you it is unlikely to be anything serious". The risk of such a project, is that, statistically, in the majority of patients who believe they are a "diagnostic mystery", none of the ideas raised by the "detectives" will really help reach a significant diagnosis (simply because there is none). There will possibly be an occasional misdiagnosis needle in the haystack, but that will be diluted by a lot of background noise. That is the one of the challenges of primary care in the first place, isn't it?

I think it would be more likely to help if the cases were ones where doctors  posted their unresolved cases where they felt the unease of a truly unresolved, and potentially serious, problem. Statistically, it would increase the utility of second opinions.



Just my two cents

Ehud



Ehud Zamir, MD, FRANZCO

Centre for Eye Research

Melbourne Australia



________________________________



From: David Meyers [dm0015 at ICLOUD.COM<mailto:dm0015 at ICLOUD.COM>]

Sent: Wednesday, 17 July 2013 5:10 AM

To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>

Subject: Re: Crowd Wisdom for Diagnosis?





Dr Lisa Sanders, the NY Times medical correspondent, has been doing this for quite a while in the Sunday magazine.  See link:  http://topics.nytimes.com/topics/news/health/columns/diagnosis/index.html.  There are also Twitter resources in emergency medicine like this.  One has to be careful to use the wisdom of crowds  (see James Surowiecki, 2004) and not the madness of crowds (Charles Mackay, 1841), if we can tell the difference.



David



David L Meyers, MD, FACEP

dm0015 at icloud.com<mailto:dm0015 at icloud.com>

Mobile: 410-952-8782<tel:410-952-8782>

Fax: 410-367-0449<tel:410-367-0449>











On Jul 16, 2013, at 1:59 PM, Bill Thatcher <BillThatcher at MINDSPRING.COM<mailto:BillThatcher at MINDSPRING.COM>> wrote:





      Yesterday I posted a short piece from Mark Graber, MD about an intriguing new website:



      CrowdMed.com  <http://www.crowdmed.com/> is a new online startup that uses the 'wisdom of the crowd' to suggest the correct diagnosis for patients with unresolved symptoms. The project is the brainchild of Jared Heyman, an internet-entrepreneur, who thought of the idea after his sister suffered through an undiagnosed illness for over three years. Cases are submitted by patients for a small fee, and anyone can register as an "MD" (medical detective - cute, eh? No license required) to suggest a diagnosis or vote on the suggestions already made.



      You can read the rest of the post from Mark Graber here:



      http://improvediagnosis.site-ym.com/blogpost/950784/Latest-News



      Bill Thatcher



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