Patient experience

PAUL FOSTER, MD pfoster at GBMC.ORG
Tue Oct 22 22:23:09 UTC 2013


The other axis to these 5 categories of error is adherence to best practice.  
 
When evidence based approaches and best practices are followed and lead to one of these errors -- its a cost of our system at its best.  The only solution is to advance science and come up with better approaches.  An example would be the occurrence of an advanced cancer in a truly asymptomatic patient, with normal appropriate screening tests and examination just prior to discovery.  This can be avoided only by improving screening practices themselves.
 
The opposite end of the axis is when these errors occur within the setting of less than best practices.  These might be over or under treatment, symptomatic or screening.  They may come from rushed examinations, leaping to conclusions, faulty data, or outdated community standards.   Here there are many straightforward opportunities to reduce cognitive bias, improve information flow and processing, and standardize approaches. 
 
We need new language which captures these distinctions in relation to the best practice axis.  We also need to transform our peer review infrastructure to  recognize and label these errors.  More precise language will allow us to see the problem more clearly, and communicate about it.
 
Paul Foster, MD FACP
PD GBMC Internal Medicine Residency


>>> "Kohn, Michael" <Michael.Kohn at UCSF.EDU> 10/21/2013 2:30 PM >>>

Dear Colleagues,

As you know, there are different types of diagnostic errors.  

In symptomatic patients, i.e. patients who are sick, we obviously want to make the right diagnosis and provide the appropriate treatment if one exists.  The two errors we make are to 1) make a wrong diagnosis and provide an inappropriate, harmful treatment, or 2) fail to make any diagnosis and fail to provide appropriate treatment.  We should acknowledge that many illnesses are best left untreated, in which case failing to make a diagnosis is fine.  Many pediatric patients brought into the ED or walk-in clinic have a SLUBI (self-limited, undiagnosed, benign illness).

In screening of asymptomatic patients, i.e. patients who are not known to be sick, we obviously want to identify pre-symptomatic disease if it is there and a useful treatment exists.  How much sense does it make to identify an untreatable pre-symptomatic disease?  The two errors we make are to 1) miss pre-symptomatic disease and therefore fail to provide useful treatment, or 2) treat pre-symptomatic disease that isn't really there or would never have caused a problem; this is "overdiagnosis".
 
Patients can tell stories about our failure to identify a pre-symptomatic disease that ultimately causes problems, but they can't tell stories about overdiagnosis; no individual patient knows for sure whether his treatment for pre-symptomatic disease worked or if he was treated unnecessarily for a disease that wasn't really there or would never have caused a problem, althoug we know from comparing groups of screened and unscreened patients that overdiagnosis exists.
 
Improving diagnosis means reducing both missed diagnosis and overdiagnosis, so I encourage the participants on this thread to read "Overdiagnosis" by H. Gilbert Welch as a counterbalance to patient stories about missed diagnoses.
 
 
Respectfully,
 
Michael
 
Michael A. Kohn, MD, MPP
UCSF
________________________________________
From: Lorenzo Alonso [ljalonso at UMA.ES]
Sent: Monday, October 21, 2013 9:46 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: [IMPROVEDX] Patient experience

I find very interesting the attitude for a doctor to say "I don,t know"
instead of "inventing" diagnosis , reassuring to the patient about the
follow-up and giving him or her advices about symptoms or situations for a
quick consultation (I have a particular example with a young patient with
several visits to the ED for abdominal discomfort; after some explanations
such as "meteorism" the  patient said to the surgeon: excuse doctor but
another doctor told me that meteorism is not a diagnosis. The surgeon
asked for more test and a diagnosis of Cronh,s disease was established.
Other aspect is the active role for the patient: example ovarian cancer is
still a disease diagnosed late. I say to my patients to ask for it to the
gynecologist in a normal gynecologic visit where usually only uterine or
cervical cancer is despicted.

Lorenzo Alonso






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