The patient experience of diagnostic error

robert bell rmsbell at ESEDONA.NET
Mon Oct 28 05:14:42 UTC 2013


Thanks David,

Wow, what a challenge when using standard computers and inputting test results, past medical history (including both social and psychological - that is often downplayed) and also the physical examination. With all of these having intensity, shades and “surface" characteristics. And then we have not even plumbed inferential processes. 

What a task for programmers!

Singularity here we come!

Amazing insight.

Rob 





On Oct 27, 2013, at 7:21 PM, David Woods <woods.2 at OSU.EDU> wrote:

> 
> 
> The post below refers to a classic illusion, but this along with many others, are not examples of how the human mind can be confused. Quite the contrary, this example reveals important and powerful aspects of how the human perception functions in a complex, ambiguous, and dynamic world. 
> 
> The illusion in question illustrates that there are limits to the remarkable property of the human perceptual system called lightness constancy (and color constancy).  Lightness and color constancy are a examples of competencies of human perception that computer vision algorithms struggle to produce, and that perceptual scientists only understand partially (yes, there are limits to human perceptual capabilities, as there are for all physical systems).   
> 
> The human perceptual system uses relationships about surface reflectance instead of surface luminance. Changes in illumination therefore do not change what we perceive as a whole and stable surface. This is in stark contrast to the current state of computer vision and machine vision models and algorithms. These typically operate on luminance and hence interpret changes in illumination as changes in surface. For example, if the illumination source were to move in this illusion, the movement of the shadow would be detected as change in the surface by many if not all of existing computational vision models. In order to manage this problem, these models will assume properties of the surface or of the illumination source, or the stability of the environment over time. For instance, one method would be to collect images of changing illumination conditions and then use these changes to compute a reflectance map, which can then be used to assess and remove future variation in illumination. Of course, this technique requires changes in illumination to determine what is constant (reflectance of the surface present over time in the scene) and what varies (luminance varies with illumination and viewing angle). The mind quickly extracts patterns in reflectance that allow direct apprehension of properties of the scene despite huge changes in luminance as sources of illumination and viewing angle change -- a remarkable capability (as a result, few people even appreciate the extreme difficulty of the problem).  
> 
> To clarify, the illusion cited helps us notice what under realistic conditions is a special human perceptual competency, and second the illusion does not address inferential processes.  How inferential processes work, and break down, is quite different.
>  
> 
> 
> 
> David Woods, PhD  木材
> Releasing the Adaptive Power of Human Systems
> 
> • Lead, Initiative on Complexity in Natural, Social & Engineered Systems
> • Co-Director, C/S/E/L Cognitive Systems Engineering Laboratory 
> 
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> On Oct 22, 2013, at 11:57 PM, Charlie Garland - The Innovation Outlet <cgarland at INNOVATIONOUTLET.BIZ> wrote:
> 
>> Here is one example of an optical illusion that, I can almost guarantee, any skeptical patient will swear that the color of square A is different than the color of square B.  And, while not technically the same as the reason for a mis-diagnosis, it can be illustrated as an example of how the mind can be confused by peripheral observations, assumptions (e.g. pattern-recognition reliance), and so forth.
>> 
>> <clip0004.jpg>
>> 
>> 
>> I'm not sure if this image will be viewable within this listserve function, whether embedded or attached, but if anyone would like to see it, you can always view the same one here: http://en.wikipedia.org/wiki/Checker_shadow_illusion
>> 
>> You, a certified, experienced medical professional, may be saying to yourself right now, "there is no way in the world that square A and square B are the same shade!"  Well, if you don't believe me, copy this image and open into Microsoft Paint (or other image editing tool), cut out a small swatch within either square, and pull it over into the other.  
>> 
>> Amazing, right?  This could be a very eye-opening exercise to educate the patient...
>> 
>> Charlie  
>> =================================================
>>  
>> Charlie Garland, President
>> 
>> The Innovation Outlet
>>     <sigimg1.jpeg>
>>      Get Plugged-In!TM
>> 
>> Main Website: www.TheInnovationOutlet.com
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>> 
>> -------- Original Message --------
>> Subject: Re: [IMPROVEDX] The patient experience of diagnostic error
>> From: Alan Morris <Alan.Morris at imail.org>
>> Date: Mon, October 21, 2013 12:51 pm
>> To: Society to Improve Diagnosis in Medicine
>> <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, "Charlie Garland - The Innovation
>> Outlet" <cgarland at INNOVATIONOUTLET.BIZ>
>> 
>> I would like to receive the citations.
>> Thank you for the offer.
>> Have  a nice day.
>> 
>> Alan H. Morris, M.D.
>> Professor of Medicine
>> Adjunct Prof. of Medical Informatics
>> University of Utah
>> 
>> Director of Research
>> Director Urban Central Region Blood Gas and Pulmonary Laboratories
>> Pulmonary/Critical Care Division
>> Sorenson Heart & Lung Center - 6th Floor
>> Intermountain Medical Center
>> 5121 South Cottonwood Street
>> Murray, Utah  84157-7000, USA
>> 
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>> 
>> 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: Sunday, October 20, 2013 6:57 PM
>> To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <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
>>     <sigimg1.jpeg>
>>      Get Plugged-In!TM
>> 
>> Main Website: www.TheInnovationOutlet.com
>> Proud Affiliate of Schaffer Consulting (featuring RapidResults® Innovation)
>> Developer of The Innovation CubeTM (Critical Thinking & Creative Problem-Solving Model/Tool)
>> Improve Your Sales: www.InnoSalesCoach.com (Applying Innovation Tools, Methods, & Insights to Your Sales/Marketing Process)
>> Increase Your Innovation Capacity: Certified Innovation CoachTM (Innovator MindsetTM Assessments)
>>  
>> LinkedIn:http://www.linkedin.com/in/innovationoutlet
>> Twitter: @innovationator
>> 
>> office: 212.535.5385
>> cell: 646.872.0256
>> 
>> "The Root Cause of Innovation: How Value-Driven Thinking Changes Everything You Do"
>>  ...my new book (2013)
>> 
>> 
>> 
>> -------- 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
>> 
>> 
>> 
>> 
>> 
>> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society for Improving Diagnosis in Medicine
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>> Save the date: Diagnostic Error in Medicine 2013. September 22-25, 2013 in Chicago, IL. 
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>> Save the date: Diagnostic Error in Medicine 2013. September 22-25, 2013 in Chicago, IL. 
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