FM: Crowd Wisdom .... lack of dx error in the curriculum

Michael Grossman Michael.Grossman at MIHS.ORG
Fri Aug 16 15:41:18 UTC 2013


Dr. Centor , as often he does,  has articulated very effectively what I truly believe to be appropiate and correct. 
One of the most important functions of clincal teaching is modeling the reasoning in determining the diagnosis and , or the approach to selection of appropriate testing utilizing the format of Evidenc Based Medicine , working through the pre-test, prevalence and posterior probabilities. 
I remain old fashion enough to use the nomogram in plotting these predictive values as described many moons ago. 
Certainly I am not correct all of the time, but this more formal approach supplements what ever "blink" phenomenon occurs to me when I am gathering clinical data.
The issue is do I have the fortitude to stick to the "protocol" when I am really certain I have hit on the diagnosis ? I can't necessarily answer that question-too many variables are active all at once. 

Michael Grossman  , MD MACP
asociate dean GME 
University of Arizona  College of Medicine, Phoenix

________________________________________
From: Robert M Centor [rcentor at UAB.EDU]
Sent: Friday, August 16, 2013 5:52 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] FM: Crowd Wisdom .... lack of dx error in the curriculum

My colleagues and I found that students and residents are more interested
in how clinicians think through problems than having us recite the latest
study.  Teaching the thought process will cause some discussion of
diagnostic error.

At least in internal medicine, the most valued teachers are explicit in
their thinking.

I think we should emphasis clinical reasoning in our curriculum,
especially during the clinical years.

Jerry Kassirer wrote this in Academic Medicine several years ago.

This is not adding to the curriculum, but rather the key ingredient for
clinicians.
==============

Robert M Centor, MD, FACP

Regional Dean, UAB Huntsville Regional Medical Campus
301 Governors Drive
Huntsville, AL 35801

Office: 256-539-7757
Fax: 256-551-4451

Chair-Elect, ACP Board of Regents

Professor, General Internal Medicine
UAB
FOT 720
1530 3rd Ave S
Birmingham, AL 35294-3407
Office: 205-975-4889





On 8/15/13 9:13 PM, "Garry Nieuwkamp" <Garry.Nieuwkamp at HEALTH.NSW.GOV.AU>
wrote:

>I have no problems with the lack of error education in medical schools.
>Everyone wants a part of medical education because this is important or
>that is important. How about just getting the medical education right and
>let the other stuff work itself out in due course.
>Garry Nieuwkamp MBBS DA FACEM MA PhD
>
>________________________________________
>From: Lorri Zipperer [Lorri at ZPM1.COM]
>Sent: Friday, 26 July 2013 11:16 AM
>To: Garry Nieuwkamp; Society to Improve Diagnosis in Medicine
>Subject: [IMPROVEDX] FM: Crowd Wisdom .... lack of dx error in the
>curriculum
>
>From: robert bell [mailto:rmsbell at esedona.net]
>Sent: Thursday, July 25, 2013 5:32 PM
>To: Society to Improve Diagnosis in Medicine; Dr.Will
>Subject: Re: [IMPROVEDX] Crowd Wisdom, Premature psych conclusions, and
>harm
>from misdiagnosis
>
>[Building on the comments of] Will and Amy,
>
>I think the main problem is that medical diagnosis is not well taught in
>medical/PA/NP schools. There are few simulator programs like the airline
>industry to repeat things time and time again, little instruction on the
>basics of diagnosis and where to get the best help/support, little
>instruction on how to get a good history and elicit meaningful symptom
>complexes and changes, etc. And little knowledge is passed on as to where
>the main errors in diagnosis come from in both the hospital and private
>practice offices.
>
>Did I hear that only 50% of teaching schools even address Errors in
>Medicine
>as a whole.
>
>Pretty awful - we are still teaching med students using 100 year old
>methods.
>
>Add to this mess to the lack of research in the area and you have one big,
>big problem.
>
>This organization could well lobby for more research and medical
>training/education in this area.
>
>Rob Bell
>On Jul 25, 2013, at 6:51 AM, Dr.Will wrote:
>
>
>Yes physicians are spending "less time" listening and caring for patients
>because of the additional typing responsibilities due to EMR and LESS eye
>contact (and if someone does the research), you will see even LESS
>effective
>communication coming out of patient due to the "hurried" office visit.
>Hence
>more "misdiagnosis".
>Second there is A LOT of chronic disease that CAUSES depression like
>symptoms.
>So most physicians should "slow down you're moving too fast, you've got to
>let the office visit last(get to the real issue)" to quote a phrase from a
>popular song.
> Will Sawyer
>Solo Family Medicine
>
>
>________________________________
>
>From: Amy Reinert [mailto:amy.reinert at GMAIL.COM]
>Sent: Wednesday, July 24, 2013 6:58 PM
>To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>Subject: Crowd Wisdom, Premature psych conclusions, and harm from
>misdiagnosis
>
>I'm coming in a little bit late to this discussion, but did want to
>respond
>to Dr. Bell's comment about women with history of sexual abuse seemingly
>living in the doctor's office.
>
>For my doctoral dissertation research, I conducted a study of women
>diagnosed with autoimmune disease whose symptoms had been dismissed by
>several physicians over the course of several years. All of these patients
>were dismissed as "psych" by male and female physicians alike (please note
>that they were screened for pre-existing mental disorders). Some
>physicians
>ran tests initially. Others declined to run tests at all. Obviously these
>women truly were ill, however, they experienced significant psychological
>harm that can reasonably be attributed to misdiagnosis or lack of
>investigation. Of course, there were also financial implications from all
>of
>these unproductive office visits. Too much to go into in depth here, but
>in
>considering the harm these patients experienced in terms of their mental
>health (being told they was nothing wrong with them when in fact their
>bodies were clearly--to them-- ill) and the worsening of their untreated
>disease, it seems that there does need to be further study of patients
>with
>unresolved symptoms. The results of my study also indicated that more
>study
>of the influencing "invisible" personal biases held by physicians is also
>in
>order.
>
>A.D. Ruzicka, Ph.D
>
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