The patient experience of diagnostic error

PULSE516 at AOL.COM PULSE516 at AOL.COM
Tue Oct 22 02:50:25 UTC 2013


Mark,
 
To comment specifically on your remark: 

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
You are the one who put it out years ago that patients need to learn to be  
"historians"   People are taught to live with diabetes, high blood  
pressure, heart disease etc. but learning to be a patient needs to be addressed  
just that way.  Too many patients are saying it isn't our responsibility to  
tell the clinician their job or what to do but there is nothing wrong with  
that and being a patient and going to patient advocacy training (yes we have  
been doing that for years) is a great way to get patients and their 
families on  board..
 
Patients (people) must learn to know their bodies and recognize  symptoms.  
Just today a woman I have been following talked about a problem  that she 
figured was something new and she didn't want to bother her  doctor.  It 
never occurred to her that it might be a symptom of something  the doctor is 
already following.
 
We have worked in diagnosis error prevention into our curriculum and  it 
falls under communication.  Written, verbal and even body language  can open 
or shut the doors on communication.  To many it is learned skill  and in a 
world of hurry up and wait,  we (the patient and our families  helping us) can 
learn to use our time appropriately.
 
 
ilene
 
 
 
 
Ilene Corina,  President
PULSE of NY
_www.pulseofny.org_ (http://www.pulseofny.org/) 
(516) 579-4711
_www.patientsafetyconsultants.com_ 
(http://www.patientsafetyconsultants.com/) 
Start  a Cautious Patient Community in your neighborhood!
http://www.cautiouspatientcommunities.org/ 

 
 
 
In a message dated 10/21/2013 12:22:59 P.M. Eastern Daylight Time,  
Mark.Graber at VA.GOV writes:

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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The Innovation Outlet
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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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