FW: [IMPROVEDX] Crowd Wisdom, Premature psych conclusions, and harm from misdiagnosis

Lorri Zipperer Lorri at ZPM1.COM
Sat Jul 27 19:57:47 UTC 2013

Forwarded by the moderator

-----Original Message-----
From: John Brush [mailto:jebrush at me.com] 
Sent: Saturday, July 27, 2013 6:36 AM
To: Society to Improve Diagnosis in Medicine; Graber, Mark
Subject: Re: [IMPROVEDX] Crowd Wisdom, Premature psych conclusions, and harm
from misdiagnosis

In addition to informing trainees about the shortcomings of heuristics, we
need to inform trainees on how heuristics help us deal with uncertainty. We
need to maximize the upsides and minimize the downsides because the use of
intuition in medicine is not going to go away in the foreseeable future.
When heuristics fail, they cause people to make mistakes in the use of logic
and probability. We need to reinforce the good use of logic and and
probability. We need to teach trainees good mental habits if we want to help
them avoid mental errors.
This is the whole point of my iBook, which, by the way, is free. I don't
have any conflict of interest, only an un-conflicted interest in teaching
better medical reasoning.
John Brush 

Sent from my iPad

On Jul 25, 2013, at 8:10 PM, "Graber, Mark" <Mark.Graber at VA.GOV> wrote:

> Deborah's stories, tragic as they are, convey an incredibly important
lesson for all of us interested in diagnostic error - namely that being more
aware of the possibility of diagnostic error can help prevent the next one.
Acknowledging that this is an 'n' of 1 demonstration, its still great to
hear that building awareness had an impact.
> Pat Croskerry has argued in several of his papers that one way to reduce
diagnostic error is to teach the inherent shortcomings of heuristic
thinking.  I was initially unconvinced, on the grounds that these are
hardwired responses, and can't be unlearned.  Deborah's ability to discover
a new diagnostic error would seem to argue that we should score one in Pat's
favor, although I wonder what was the more dominant influence for Deborah:
knowledge of cognitive bias, or just knowledge that these errors are so
> Mark Graber
> Senior Fellow, RTI International
> Founder and President, Society to Improve Diagnosis in Medicine
> ________________________________
> From: "Dr.Will" <dr.will at FUSE.NET>
> Reply-To: Society to Improve Diagnosis in Medicine 
> Date: Thu, 25 Jul 2013 16:32:00 -0400
> Subject: Re: [IMPROVEDX] Crowd Wisdom, Premature psych conclusions, 
> and harm from misdiagnosis
> Hello Deborah,
> And then you add additional work the physician must do per patient
visit(EMR) taking them away from the patient and you end up with a
"misdiagnosis" because there was very little clinical time spent with the
patient due to extra work requirements.
> So wrong diagnosis, but an effective billing software system so the
hospital was paid well. Seemingly at the expense of the patient.
> It happens too frequently.
> Will Sawyer, MD
> Solo Family Medicine
> Cincinnati, Ohio
> ________________________________
> From: Deborah Akinniyi [mailto:deborah.akinniyi at YALE.EDU]
> Sent: Thursday, July 25, 2013 2:11 PM
> Subject: Re: [IMPROVEDX] Crowd Wisdom, Premature psych conclusions, 
> and harm from misdiagnosis
> Hello everyone,
> My name is Deborah Akinniyi, and I'm an internal medicine resident who
became interested in diagnostic error during my third year of medical school
after my first patient died... When he died, I wept... and I was angry. My
team said there was nothing we could do, that these things happen, and that
with patients like him the outcome wasn't surprising. I didn't accept these
notions, because deep inside, a gnawing feeling told me we were wrong;
despite the type of patient he was, or the psychiatric and medical
comorbidities he had, his death could have been prevented.
> These feelings pulled and pushed me towards careful review of his case,
acceptance that even the most seasoned doctors make mistakes, and my
introduction to diagnostic error. I confirmed that we were wrong, and found
that my patient's story was an unfortunate case of delayed diagnosis,
cognitive biases, and diagnostic error proved deadly. Since then, I've
remained interested in reducing diagnostic error through various means,
including sharing my experiences with other physicians so that we can all
learn from it.
> I have a case of a patient who was being "dismissed as psych" so strongly
that her inspiratory chest pain, palpitations, and sinus tachycardia were
dismissed as consequences of her pre-existing psychiatric disorders. Prior
to coming on service, I was told that she was completely fine, had no
current medical issues, and was just waiting for an inpatient psych bed. I
was told, "Don't be alarmed if she complains of chest pain... It's just the
way her anxiety presents." I was even given specific instructions not to
pursue a pulmonary embolism (PE) work-up... "She does not have a PE."
> It turns out, this patient had multiple PE's. She also had a personal
history of spontaneous abortions, and a family history of blood clots.
Later, we confirmed that in addition to her pre-existing psychiatric
disorders, she has a genetic clotting disorder.
> When I reflect on this case, I'm forced to realize that had I not been
aware of how common various biases can lead to delayed diagnosis and
diagnostic error, this woman may have continued to go untreated, worsening
her physical health, and her concerns may have continued to be minimized and
dismissed, worsening her mental health. I also suspect that patients with
pre-existing psychiatric disorders likely suffer from delayed and
misdiagnosis more commonly, and agree that the implications this has on the
financial burden, patient safety, mental health, physical health, and the
overall doctor-patient relationship in this group are frightening.
> I plan to fully analyze this case from a diagnostic error standpoint and
to review the literature on the specific biases that affect the care of
patients with pre-existing psychiatric disorders. I plan to eventually write
a case report on this, and am sure that through that process, I'll learn
even more about diagnostic error and how to prevent it. If any of you have
experiences, articles, or papers you'd like to share, please send them my
way! Also, if you have any questions for me, or any advice to help me as I
continue through residency and develop as a physician, I'm all ears and open
for mentorship. I'm inspired by you all, and I look forward to continuing
these conversations.
> Sincerely,
> Deborah Akinniyi
> Deborah C. Akinniyi, MD, MS
> Yale Internal Medicine Residency Program
> MD, George Washington University, '12
> MS/BS, Stanford University, '08
> Website: http://fickprinciple.wordpress.com
> Email: deborah.akinniyi at yale.edu, chinenye at stanfordalumni.org

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