Missed and Erroneous Diagnoses Common in Primary Care Visits

Robert Bell rmsbell at ESEDONA.NET
Tue Dec 31 01:48:47 UTC 2013


FOR POSTING TO THE LIST

And another big impediment is resistance to change. I recall antibiotics for H. pylori infections that took about 20 years to come to the US from Australia.

It seems as though a pervading environment of half-truths, such as those with advertising and political statements, somehow desensitize us and allow us to think that evidence based care can be ignored or modified.

How would we change that?

Rob Bell

Sent from my iPad

On Dec 30, 2013, at 3:44 PM, Alan Morris <Alan.Morris at IMAIL.ORG> wrote:

> I agree that Bayes theorem, prior and posterior probability considerations, an probabilistic thinking in general have provided mush important illumination of clinical decision-making processes.  I support the arguments in these past several  important communications.  Nevertheless, we are missing an important "final common pathway" that leads to unnecessary variation in clinical decision-making, and therefore in both clinical practice and clinical research – the clinician decision-maker and his/her cognitive limitations.  As john Bush indicated, he does not expect the clinician to actually calculate the probabilities involved during decision-making.  John implicitly, I believe, is acknowledging the limitations of the unaided human decision-maker here.
> 
> Humans are the planet's tool-makers par excellence, but we are not making the efforts necessary to provide clinical decision-makers with the tools they require for making consistent, evidence-based, clinical decisions.  Without such decision-making aids, clinicians will be unlikely to elevate healthcare from its current unacceptable state of unnecessary variation, and deviation from evidence-based care.  Since we are speaking of cardiovascular issues, I recommend the paper by Fonarow et al., below.  It points to the low compliance with evidence=based care for heart failure patients treated in cardiology clinics (the sites with the most educated and aware practitioners).
> 
> Fonarow GC, Yancy CW, Albert NM, Curtis AB, Stough WG, Gheorghiade M, et al. Heart Failure Care in the Outpatient Cardiology Practice Setting / CLINICAL PERSPECTIVE. Circulation: Heart Failure. 2008;1(2):98-106.
> 
> 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
> 
> Office Phone: 801-507-4603
> Mobile Phone: 801-718-1283
> Fax: 801-507-4699
> e-mail: alan.morris at imail.org
> e-mail: alanhmorris at gmail.com
> 
> 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: Monday, December 30, 2013 11:46 AM
> To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> Subject: Re: [IMPROVEDX] Missed and Erroneous Diagnoses Common in Primary Care Visits
> 
> John (Dent) - Because what John (Brush) discusses in his email and book, you may want to supplement your training program with one more tool -- one that is available for free also, and it is designed specifically to help individuals avoid early closure, which (IMHO) is one of the primary contributors to Diagnostic Errors, and other manifestations of non-critical thinking.  I have begun working with health science academies and nursing schools in this very same approach.
> 
> The tool is called "Cubie" (a.k.a. TheInnovationCube.com) and you can request a free, printable prototype of the tool (a logical model for triggering and guiding some of the types of probing questions that John B. recommends) at the end of this brief video: http://portal.sliderocket.com/BIWIR/Cubie-TOTB, or you can simply send me an email and I'll attach the PPT file for you to print out locally.  If you'd like additional context on how and where to use the tool, I'd be more than happy to elaborate.
> 
> Kind regards, and sincere wishes for a happy, safe, prosperous new year...
> Charlie Garland
> 
> =================================================
>  
> Charlie Garland, President
> 
> The Innovation Outlet
>     <sigimg1>
>      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] Missed and Erroneous Diagnoses Common in
> Primary Care Visits
> From: "Dent, John M *HS" <JMD5K at HSCMAIL.MCC.VIRGINIA.EDU>
> Date: Mon, December 30, 2013 12:30 pm
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> 
> While it’s true there is a rich literature ( and those are seminal papers), as a cardiovascular fellowship training program director, I’ve found that our residents and fellows often lack an intuitive grasp of what John is discussing.  We’re planning to use his iBook in our training program, because it is so accessible and clear in its descriptions and examples.
>  
> John Dent MD MS
> Professor of Medicine
> University of Virginia Health System
>  
> From: Dean F. Sittig [mailto:Dean.F.Sittig at UTH.TMC.EDU] 
> Sent: Monday, December 30, 2013 11:54 AM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] Missed and Erroneous Diagnoses Common in Primary Care Visits
>  
> These concepts have been covered in the medical informatics literature for many years. See this seminal paper from 1959 that is often given credit for starting the field of medical informatics.
> Dean
> http://www.cs.tufts.edu/comp/150AIH/pdf/LedleyLu59.pdf
> and here is another practical implementation of these concepts from one of my PhD advisors: Homer Warner
> http://jama.jamanetwork.com/article.aspx?articleid=331443
>  
>  
> From: John Brush [mailto:jebrush at ME.COM] 
> Sent: Sunday, December 29, 2013 12:48 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] Missed and Erroneous Diagnoses Common in Primary Care Visits
>  
> Hi Bimal,
>             Wow, you have given me a lot to respond to.
>             Regarding your point #1, I think you are disregarding the prior probability that would be determined by the situation and context. There may be a cold wave moving in, which is the new evidence, but you have disregarded the baseline conditions. Are you in Florida or Minnesota? Is it winter or summer? These conditions will give you some general idea of the baseline probability of snow. You should have some general idea about whether you are initially skeptical, a believer, or neutral about the proposition that it will snow tomorrow.
>             Regarding #3, prior probability is your starting point, to which you apply new evidence to derive a posterior probability. That posterior probability can then become the prior probability for a new bit of additional evidence. You can daisy-chain new evidence updates to constantly update your probability assessment. You can easily do this with likelihood ratios, but you need to convert probability to odds before you start multiplying by the LR’s, and then convert post-test odds back to probability in the end.
>             Regarding #6, I agree that it is important to factor in the strength and accuracy of new information. Likelihood ratios help you do that. They incorporate the sensitivity and specificity of new information to tell you how much weight to put on a positive test result or a negative test result.
>  
>             So here’s how I would put this into practice. You start developing some idea of the possibilities and their associated probabilities at the very beginning of a patient encounter when you elicit a chief complaint. This starts you thinking about the possibilities. You start general - is it acute or chronic, localized or systemic, serious or mild, injury or illness? You ask a series of probing questions, and you start to develop in your mind a short list of the possibilities. You continue to probe with more targeted questions to get a clearer idea of the possibilities. Once you finish the history and physical, you should have a list in your mind of 3-5 possible diagnoses. But you generally wouldn’t rank all 5 of them equally. You would rank them in your mind according to their relative likelihood. If the diagnostic possibilities are mutually exclusive and collectively exhaustive (it has to be one of them), the total cumulative probability of all of your possibilities has to add up to one. Thus, you can start to give a provisional probability to each possibility. This is the process of early hypothesis generation. At this point, you have developed a list of hypotheses, sorted according to relative probability, but you haven’t concluded anything yet. You now have to go through the process of iterative hypothesis testing to decide whether to accept or reject each hypothesis, until you reach a final conclusion.
>             Let’s say that the patient has chest pain. There are typical and atypical features. After questioning and examining the patient, you think it may be anxiety or angina, but could be pericarditis or GERD, or even a dissection. You may think that anxiety and angina are likely, pericarditis and GERD are less likely, and aortic dissection is very unlikely. Knowing that the probabilities of all the possibilities add up to one, you can start to estimate prior probabilities, based on the relative probability of you 5 possibilities.  We’ll assign initial probability estimates, giving anxiety and angina 0.3 each, dissection 0.04, which leaves 0.18 for both pericarditis and GERD. You could tinker with the numbers a bit, but this is a starting point. You look at the CXR and see no mediastinal widening and decide that dissection is so low that you will discard it. You decide to do a stress echo to evaluate for the possibility of angina. Your prior probability is 0.3 giving a prior odds of 0.43. A stress echo has a LR(+) of 6 and a LR(-) of 0.12. Thus, a positive stress echo changes the odds to 2.6, which is a post-test probability of 0.72, whereas a negative stress echo changes the odds to 0.05 and a post-test probability slightly less than 0.05. Let’s say that the stress echo is negative and there’s no rub on exam. Thus, the probability of angina and pericarditis goes way down, and the probability of anxiety or GERD has to rise dramatically. 
>             I’m not suggesting that we should make these strict numerical calculations on every patient. But this is the system that we all use intuitively, and the expert, through experience, has a sense of the probabilities, and how to weight the new evidence. This is the essence of expert intuition for medical diagnosis.
>             This is obviously a Bayesian approach. The usual criticism of the Bayesian approach is that the estimation of the prior probability is too subjective. But you have to get your thinking started somewhere. This system of thinking helps us avoid some common pitfalls, like base-rate neglect and early closure. 
>             All of this is in my book! I self-published my book as a iBook so I could make it free. If you have an iPad, you can go to the iBookstore and download it. This discussion in in Chapters 3 and 4. I hope this is helpful.
> John
>  
> John E. Brush, Jr., M.D., FACC
> Professor of Medicine
> Eastern Virginia Medical School
> Sentara Cardiology Specialists
> 844 Kempsville Road, Suite 204
> Norfolk, VA 23502
> 757-261-0700
> Cell: 757-477-1990
> jebrush at me.com
>  
>  
>  
> On Dec 26, 2013, at 4:55 PM, Bimal Jain <bjain at PARTNERS.ORG> wrote:
>  
> Hi John, thank you for your many insightful comments. Let me respond in the numbered points below. 1. Let us take your  example of 75 percent chance of snow tomorrow. If we absolutely wished to know if it would snow or not tomorrow due to some very important event, such as launch of a space capsule, we shall seekstrong evidence for that particular day. Suppose this evidence is a cold airfront meeting a moistureladen warm airm airfront, which has a high likelihood ratio for snow, we will be nearly certain, I suggest, it will snow tomorrow, regardless of prior chance (probability of snow tomorrow. 2. We are in a similar situation in clinical diagnosis, where we aim to diagnose a disease correctly in a given , particular patient. 3. The important point is, a prior probability is not a measure of prior evidence in a given patient. It only sets the order in which we test various suspected diseases. However, a high prior probability could be trumped by other factors, such as potentially serious consequences of a disease or ease of testing it. 4. I think the danger of considering prior probability as prior evidence is that a very low prior probability may be talen as strong evidence against a disease which may be ruled out without testing. 5. In any case, we need to investigate role of probability by looking at diagnosis in actual practice and noting errors. 6. Thus we find cardiologist reading EKGs to diagnose Acute MI from acute EKG changes and radiologists to diagnose acute pulmonary  embolism from positive chest CT angiogram and deep vein thrombophlebitis from positive venous ultrasound study without knowledge of prior probabilities of these diseases. We need to look at accuracy rates of these diagnoses to see if any errors are being made. 7.. It would be helpful if we established institutional, regional and national registries for recording diagnostic errors of various diseases. They could then be studied to classify various errors and perhaps identify their causes. 8. My hunch is most diagnostic errors occur due to failure to think of and test for diseases with low prior probabilities. This could be eliminated to a great extent by teaching that a prior probability is not evidence for or against a disease in a given patient.
> 
> 
> 
> 
> 
> 
> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society for Improving Diagnosis in Medicine
> 
> To unsubscribe from the IMPROVEDX list, click the following link:<br>
> <a href="http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1" target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1</a>
> </p>
>  
>  
> 
> 
> To unsubscribe from IMPROVEDX: click the following link:
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
> 
> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
> 
> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society for Improving Diagnosis in Medicine
> 
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>  
> 
> 
> To unsubscribe from IMPROVEDX: click the following link:
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
> 
> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
> 
> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society for Improving Diagnosis in Medicine
> 
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
> 
> 
> 
> To unsubscribe from IMPROVEDX: click the following link:
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
> 
> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
> 
> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society for Improving Diagnosis in Medicine
> 
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
> 
> 
> 
> To unsubscribe from IMPROVEDX: click the following link:
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
> 
> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
> 
> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society for Improving Diagnosis in Medicine
> 
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
> 
> 
> 
> To unsubscribe from IMPROVEDX: click the following link:
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
> 
> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
> 
> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society for Improving Diagnosis in Medicine
> 
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
> <sigimg1>








HTML Version:
URL: <../attachments/20131230/c41a4ba0/attachment.html>


More information about the Test mailing list