bias vs participation

Follansbee, William follansbeewp at UPMC.EDU
Fri Jul 19 18:55:36 UTC 2013


These are good points, but as someone new to the discussion I did want to offer a couple other thoughts. I admit that I was a little surprised in reading the dialogue to see the number of postings that were promoting commercial interests.

The benefits of cooperative relationships between medicine and commercial interests are beyond question; both have and should continue to contribute in critical ways to progress. But it is also important to keep the boundaries well defined.

With respect to COI policies in academic circles, our center for one has extremely strong policies, and I believe many others do as well, and more will necessarily follow. Requirements go far beyond disclosing connflicts of interest. It is not permitted to have them at all unless they are approved, in advance, by the Dean. This covers a very broad range of potential COIs and penalties for violation can be severe.

If commercial postings are permitted on a Society list serv, it would be desirable as a matter of policy that claims that are made be backed up with hard data, documenting successful implementation of a product over time in a large number of patients, with demonstrated impact on accuracy. Isolated case examples do not serve that purpose. While I support the concept of computer decision support tools and hope that they will one day have an important role, the clinical impact thus far has been limited. When I came to the Univ of Pittsburgh in 1980, it was one of the pioneers in this field, and there was great enthusiasm for its potential impact. . 30 years later that impact, at least in our center, has been very  limited. Over the same three decades, numerous companies have come and gone in the process. Perceived obstacles have been the high overhead of use in terms of time, the failure to fit efficiently into work flows, and the lack of specificity in output. If the correct diagnosis is in a differential diagnosis list of 30 possibilities, it has limited utility.

I do genuinely support the continued development of these tools and believe that they will have an important potential role to play.  But in terms of discussion on a Society website such as this, it might be good to be cautious not to blur the boundaries between data and promotion.

Respectfully,

Bill

William P. Follansbee, M.D., FACC, FACP, FASNC
The Master Clinician Professor of Cardiovascular Medicine
Director, The UPMC Clinical Center for Medical Decision Making
Suite A429 UPMC Presbyterian
200 Lothrop Street,
Pittsburgh, PA 15213
Phone: 412-647-3437
Fax: 412-647-3873
email: follansbeewp at upmc.edu<mailto:follansbeewp at upmc.edu>


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________________________________
From: Swerlick, Robert A [rswerli at EMORY.EDU]
Sent: Thursday, July 18, 2013 6:12 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: bias vs participation

This crossed my mind as well.  The listserv might be well served with a boilerplate declaration for anyone who promotes any approach for which they can gain financially.

However, I think we will not be well served with a prohibition regarding commercial interests and products.  I am not sure that our salvation in terms of diagnostic error and decision support is likely to come from the non-commercial world (whatever that means…see below). While financial conflict  issues have been highlighted primarily focused on non-academic circles, there are substantial hidden COI within academic circles, especially academic clinical practice. COI is not called into question when one talks about a particular intervention which creates clinical revenues and margins (e.g –  surgery, imaging studies, etc) for a specific person or entity who might be hawking this. Not an entirely consistent position or one that can be justified on any rational level.

We make an artificial distinction between the non-profit and commercial worlds. The first term is a non-sequitor. Those entities that fail to generate profits generally fail to survive. We are all commercial entities unless we are independently wealthy.

Bob


From: Roy Perlis [mailto:rperlis at chgr.mgh.harvard.edu]
Sent: Thursday, July 18, 2013 2:12 PM
To: Society to Improve Diagnosis in Medicine; Art Papier MD
Cc: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: Crowd Wisdom for Diagnosis?

On many forums there are rather strict rules against posting 'use my commercial product' advertisements. Might be worth considering here.

On Jul 18, 2013, at 2:07 PM, "Art Papier MD" <apapier at LOGICALIMAGES.COM<mailto:apapier at LOGICALIMAGES.COM>> wrote:
Yes clinical decision support, and using tools at the time of action, instead of relying on memory alone needs to be taught and adopted widely.  Wonderful systems like Dxplain, Iliad, QMR, PKC  were developed 30 years ago or more, but never widely adopted.  Kahneman asserts that System 2 thinking is hard and humans don’t like to spend much time really thinking and being analytical.  Humans actually prefer to not use their brain to think, process and solve!  It is too difficult Kahneman argues, we are lazy and prefer quick, blink type judgements.  In thinking about diagnostic CDS, we need to realize that the output of diagnostic CDS cannot increase cognitive burden, it must make answers more obvious.  So yes we need to create and teach to systems that help the clinician capacity to remember and process, but we must focus on the output of CDS, these systems must relieve cognitive burden and make it easier to see answers.   For anyone on the list that is curious about a different approach to CDS please visit www.visualdx.com<http://www.visualdx.com>  VisualDx has a 98% renewal rate at hospitals, is used in over half of US medical schools, and over 1500 hospitals and large clinics.   Ten of thousands of clinicians use VisualDx to assist in pattern recognition and diagnosis.   Here is just one example of how CDS is used in busy work environments http://www.visualdx.com/user-stories/gonococcemia  Please feel to contact me off the list with research questions or collaborative ideas.

Art Papier MD, Logical Images,
Associate Professor of Dermatology and Medical Informatics
University of Rochester

From: Hoffer, Edward P.,M.D. [mailto:EHOFFER at PARTNERS.ORG]
Sent: Wednesday, July 17, 2013 2:01 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: Crowd Wisdom for Diagnosis?


I would suggest hat rather than trust to serendipity - ie, someone on the list might have some useful ideas - that doctors with a puzzling case should avail themselves of computer-based clinical decision support systems such as DXplain (visit dxplain.net<http://dxplain.net>) or Isabel.  These have been well-proven to be useful in improving one's differential diagnosis.



Ed



Edward  P Hoffer MD

MGH Lab of Computer Science

________________________________
From: Peggy Zuckerman [peggyzuckerman at GMAIL.COM<mailto:peggyzuckerman at GMAIL.COM>]
Sent: Wednesday, July 17, 2013 12:27 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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



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