The patient experience of diagnostic error

Goodson, William, M.D. GoodsoW at CPMCRI.ORG
Mon Oct 21 18:11:53 UTC 2013


Hi All,
I watch this dialog, but rarely comment.
This morning I just finished seeing a patient whose question I could not answer off the top of my head. I could make a ballpark estimate, but not give a reliable answer.  I went to an on-line risk calculator for the Gale Breast Cancer Risk model and then looked up an article on PubMEd.
She was not bothered by either.  I just told her that was what I was going to do.  I think the message is that patients appreciate us being careful to get things right for them, and they accept that there are details that are best checked.  For example, no matter how many times I have written for anastrozole, I always check the dose.  Same for sedatives such as alprazolam.
They key is to be clear that you know exactly WHERE to look and it is too important to trust memory.
Just my impression, and I've been at this a few years.
Cheers,
Bill Goodson

William H. Goodson III, MD
Senior Clinical Research Scientist
California Pacific Medical Center Research Institute
2100 Webster St, #401
San Francisco, CA 94115
415.923.3925
FAX 415.776.1977
www.drwilliamgoodson.com

________________________________________
From: Graber, Mark [Mark.Graber at VA.GOV]
Sent: Monday, October 21, 2013 8:44 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] The patient experience of diagnostic error

Besides showing us one of the most clever logo's I've seen in a long while, Charlie raises a very interesting point - can we somehow orient our patients to be be more understanding of the diagnostic process, and thereby improve it.  Some other ideas:


 *   Can we better orient them to our need to consult medical knowledge?   Research studies show that some\many patients think less of physicians looking something up during the visit.
 *   In a related vein, can we better orient them to the benefits of using decision support resources?  In a recent study, Hardeep and I studied the use of simple checklists to reduce dx error by ER MD's.  Despite being shown a video on how to review the checklist WITH THE PATIENT and the benefits of doing so, none of the 17 ER docs were comfortable enough to actually do that.  They all just reviewed the checklists privately, reducing their value.
 *   Can we better orient them to the fact that we're always playing the odds?  Its human nature to want to know 'the answer' to what ails us, and the current medical model persists in teaching this paternalistic model of  the all-knowing MD.
 *   Can we better orient patients to the dynamic aspect of diagnosis and how\when to get back to us if their symptoms evolve, if they aren't responding to treatment.  This has great potential to reduce dx error, IMHO

Mark


Mark L Graber, MD FACP
Senior Fellow, RTI International
Professor Emeritus, SUNY Stony Brook School of Medicine
Founder and President, Society to Improve Diagnosis in Medicine



________________________________
From: Charlie Garland - The Innovation Outlet <cgarland at INNOVATIONOUTLET.BIZ>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Charlie Garland - The Innovation Outlet <cgarland at INNOVATIONOUTLET.BIZ>
Date: Sun, 20 Oct 2013 20:57:53 -0400
To: <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] The patient experience of diagnostic error

Let me add a new and slightly different perspective to this, and that is one I've recently learned from Dr. Alex Lickerman.  He can tell you better himself, but in a nutshell, many (most) physicians rely upon pattern-recognition as their logical guide to Dx.  This is not at all unreasonable; yet, while retaining perhaps between 90 - 95% or greater accuracy, it does allow in the opportunity for misdiagnosis.  Relying on patterns is a form of "early closure" (i.e. not seeking additional "what if's" or "what else's" as alternatives, prior to drawing a conclusion).

This is one of many different examples of a "thinking error" that is completely natural, normal, and typical to all humans.  There will always be inaccuracies, regardless of how "perfect" anyone's personal expertise, experience, training, mentorship, equipment, stress-level, etc. might be, or appear to be.  One way that it might be interesting to research is to experiment with different ways of explaining to a patient (and/or his/her family members) that MDs are human beings, and always subject to error, even if extraordinarily small percentages of the time.

One could give a patient/caregiver one or more examples that test their own ability to make the logical diagnosis, or select the right answer, etc., just to show them that -- even when metacognitively prepared and alerted to it -- they, themselves, will still get the answer wrong, despite what their own senses, assumptions, and so forth are telling them.  There are many visual tests like this, that perhaps you're all aware of.  If not, let me know and I'll send you references.

Best,
Charlie Garland

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-------- Original Message --------
Subject: Re: [IMPROVEDX] The patient experience of diagnostic error
From: Leonard Berlin <lberlin at LIVE.COM>
Date: Sun, October 20, 2013 7:32 pm
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG


In his book a few years ago, Jerome Groopman called this "diagnosis momentum."  In radiology we call it the "alliterative error." Once a diagnosis is in play, it is very difficult to convince the physician to consider an alternative diagnosis.

Len Berlin

________________________________
Date: Sun, 20 Oct 2013 15:02:37 -0400
From: lee.tilson at GMAIL.COM
Subject: Re: [IMPROVEDX] The patient experience of diagnostic error
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

I used to be a philosopher / logician.

My biggest question is "How are doctors intellectually seduced into error?"

There are many answers, perhaps a different one for each different episode of misdiagnosis.


In my case, I am aware of two misdiagnoses involving my family that have the following logical structure.

There were several symptoms / abnormal findings to be explained by a correct diagnosis. Both of my family's misdiagnoses were cases in which the treaters had explanations (diagnoses) of the symptoms / abnormals, but the explanations (diagnoses) the treaters made were not nearly the best explanations of the symptoms / abnormals.


My son had three abnormal symptoms / findings after being admitted for meningitis:

     abnormal brain scan with cerebellar tonsils in the top of the spinal canal


     abnormal respirations - Cheyne Stokes respirations

     abnormal heart rhythm.

The first item listed on the informed consent sheet was "cerebral edema"


Cerebral edema explained all of his abnormal findings.

The treaters insisted that the cerebellar tonsils were a sign of Arnold Chiari malformation of the brain, something my son never had.


I could not get the treaters to consider the "cerebral edema" explanation of the abnormals even though it was a better explanation for several reasons, and it was also the most dangerous.  It was better because 1.  it was a simpler explanation - one explanation covered all of these abnormal symptoms / findings, 2. it did not require any new assumptions about extremely rare underlying, undiagnosed congenital anomalies, 3. edema fit perfectly in the context of the disease that had been diagnosed.


Objectively, edema was just a better explanation.

However, once someone considered "Arnold Chiari malformation," it was impossible to get them to consider alternate explanations.


Subsequent studies proved there was no Arnold Chiari malformation.

_________________________________________________


I realize that my analysis is unusual. We all bring different things to the table. I brought my background in logic and philosophy.


Let me know if you find this helpful







On Sat, Oct 19, 2013 at 8:01 AM, Siggs, Tim <ts228 at leicester.ac.uk> wrote:

Good afternoon all,

 I am a Clinical Psychology trainee at the University of Leicester, UK, with an interest in Diagnostic Error and am conducting research into this area for my doctoral thesis. As a clinical psychologist to be,I am particularly interested in the patient experience of diagnostic error with a view to understand the implications of either experiencing, or perceiving the experience of, a diagnostic error with reference to future health behaviours in patients with chronic illnesses e.g. self management of a chronic condition, adjustment, treatment adherence etc. I have followed this listserv for a number of months and have found it to be an interesting and insightful source of topical information, thank you all.

 I am writing today to ask for thoughts and suggestions regarding my research both generally and for a specific question. Firstly there appears to be a lack of published studies exploring the depth of experiencing diagnostic error from a patient perspective, there are several studies looking at adverse events as a whole which include diagnostic error within them (e.g. Elder et al., 2005; Entwistle et al., 2010; Kistler et al., 2010; Kuzel et al., 2004; Mazor et al., 2012; Molassiotis et al., 2009; Ocloo, 2010), but do not offer specification of the diagnostic error experience in itself, and I believe that the impact may be very different for diagnostic error. I feel that illuminating this perspective may help to address the psychological and emotional impact of diagnostic error such as that which can present in a medical psychology department, and this knowledge may also inform ideas regarding the process of diagnostic error from the patient's perspective. So my question to ask is does anyone know of any studies, particularly qualitative, that examine the patient experience of diagnostic error or have any particular thoughts on this topic area? In particular I'm interested to know if there are any identified (evidence based?) approaches to supporting patients who have experienced diagnostic error anyone is aware of?

 Having searched much of the literature I am cognizant of the moves to bring the patient into the patient safety process and also diagnostic error and hope that my proposed research can add to this. Any thoughts or ideas you may have are welcomed.

 Many Thanks

 Tim

 Tim Siggs
 Trainee Clinical Psychologist
 University of Leicester
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