The patient experience of diagnostic error

Nonie Leonidas nonieleonidas68 at GMAIL.COM
Tue Oct 22 02:06:57 UTC 2013


Hi Mark,

I think the three areas we all should improve to reduce Diagnostic Errors
are:

    Medical Education and the Students
    The practicing physician
    The patient and public

Here in the Philippines I give lectures to Medical students, physicians,
and educate the public.

The area that I enjoy most is writing for a Philippine Daily Inquirer, the
largest national paper, about
    How to Reduce Diagnostic Errors.

Below are my latest published columns in the Editorial an Opinion page.

http://opinion.inquirer.net/54103/how-you-can-help-reduce-errors-in-diagnosis


http://opinion.inquirer.net/51421/the-sil<http://opinion.inquirer.net/51421/the-silent-medical-tsunami>
ent-medical-tsunami                   April 25.13


http://m.inquirer.net/opinion/?id=63317
  Oct 14.13


http://opinion.inquirer.net/58375/a-different-way-of-teaching-learning-medicine


http://opinion.inquirer.net/60947/rethinking-blood-transfusion        Sept
13.13


Leonardo L. Leonidas, MD

Assistant Clinical Professor in Pediatrics (retired 2008)

Distinguished Career Teaching Award, 2009

Tufts University School of Medicine, Boston, USA

e mail: evidencebasednews at gmail.com


END




On Mon, Oct 21, 2013 at 11:44 AM, Graber, Mark <Mark.Graber at va.gov> wrote:

> 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
>
> =================================================
>
> Charlie Garland, President
>
> The Innovation Outlet
>    [cid:3465200667_2083990]
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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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