Ideas on improving rates of missed/delayed diagnoses in PCP type visits.

Georges Bordage bordage at UIC.EDU
Sun Jan 19 15:56:26 UTC 2014

UpToDate, MDConsult, etc. are only as good as the quality of the 
questions used to access them!  It was Chuck Friedman who said (2011 
AAMC-RIME Address), "You need to know something, to find out what you 
don’t know."  Simply fishing around is not likely to improve things.
Cheers.  Georges B.

On 1/18/2014 5:33 PM, Vic Nicholls wrote:
> That is a very interesting observation.
> I think it would be easier to point out that are those of us who 
> "googled" medical resources and by using things like UpToDate, 
> MDConsult, etc. found our diagnoses. Maybe that would be helpful when 
> a doctor doesn't know what is going on, as it would give differential 
> diagnoses to work through.
> I can understand doctors being hesitant to try new drugs or the like 
> (unless the patient was ok with it) but I am not sure how reviewing 
> the literature like many of us do to find our diagnoses is a problem. 
> It seems it would cut down on the rates of missed/delayed diagnoses, 
> the #1 cause of lawsuits. Not only that, faster time to dx and 
> treatment, especially for PCP's, would keep a patient off the 
> "frequent flyer" list and give room to others who need medical care.
> Maybe someone can explain how what I would think would be a win win 
> situation is not.
> Victoria
> On 1/17/2014 10:08 AM, Amy Reinert wrote:
>> Someone earlier in this thread mentioned the difference between 
>> "special cases" and discussion of general principles.
>> Rob's point here about communication, combined with the personal 
>> anecdote, brings an important aspect of research, as well as problem 
>> solving, into focus. Misdiagnosis, on most fronts, appears to 
>> originate in the domain of human experience. There is a lot of great 
>> science and techonology that supports the ability to make accurate 
>> diagnoses, but as we've noted in so many different words, at the end 
>> of the day, the practice of medicine is a human endeavor. When 
>> researchers must reach for anecdotal reports to support theories or 
>> arguments, it is an indicator that there is a significant gap in the 
>> research. There has been a great deal of discussion on another thread 
>> about logic and decision making processes. All well and good, and 
>> important, I think, to improving diagnosis. However, in reading these 
>> postings and reviewing the literature, it has become apparent to me 
>> that there is a need for qualitative research regarding 
>> misdiagnosis-- both from the patient and physician perspectives. I 
>> believe that thoughtful collection of anecdotal reports, combined 
>> with meta analysis of the existing literature, will guide the way to 
>> significant advances in improved diagnostic accuracy.
>> Best--
>> Amy Ruzicka, Ph.D.
>> On Thursday, January 16, 2014, Robert Bell <rmsbell200 at 
>> <mailto:rmsbell200 at>> wrote:
>>     Mis-diagnosis and delayed diagnoses are common, but so is delayed
>>     communication of diagnosis, particularly in stressful situations.
>>     A relative waited 3 weeks after a mammogram to be told that a
>>     breast biopsy was negative for cancer.
>>     Rob Bell
>>     Sent from my iPad
>>     On Jan 8, 2014, at 5:49 AM, Vic Nicholls <nichollsvi2 at GMAIL.COM>
>>     wrote:
>> > I can identify with this. I had a doctor who had seen cachexia
>>     and the like, also figured out the first time from "normal" blood
>>     work (normal for ranges but not for me) that I had a nutritional
>>     anemia. The "normal" blood work had items showing high normal/low
>>     normal values in the appropriate places. Allowing a computer or a
>>     person to simply read those and not be able to interpret symptoms
>>     and then the blood work in light of that, was what caused months
>>     of delay in getting treated.
>> >
>> > I was able to figure it out by "google". I could figure it out
>>     by searching medical resources (UpToDate, ClinicalKey,
>>     Medline/Pubmed) because the criteria were never used by doctors.
>>     In other words, 10 doctors from various groups never used the
>>     correct criteria for diagnosis.
>> >
>> > When the rates of misdiagnosis and delayed diagnosis are from 20
>>     to even 40%, we've gone past "anecdotal". The biggest item doctors
>>     are sued for are this. The lack of relying on the medical
>>     literature to diagnose is a problem.
>> >
>> > I can show that this issue is ignored. I've got enough links
>>     about doctors and hospitals hiding their heads in the sand on it.
>>     Just a few below. We're here to get a dialogue to see how to fix
>>     it without lawyers and people getting hurt.
>> >
>> > On top of that, claiming psych issues doesn't work. I got called
>>     bipolar with no evidence of mania or depression. I got labelled as
>>     anorexia nervosa without any evidence of excessive exercise or the
>>     diet that would be normal for an anorexic.
>> >
>> > pg 202-203, Medical Blunders by Robert Youngson and Ian Schott
>> > Psychiatric misdiagnosis is common. An American doctor, Robert
>>     S. Hoffman, blames the process on a chain of irreversible and
>>     tragic events, whereby 'a primary physician applies a preliminary
>>     diagnosis of mental disorder which is decisive in determining the
>>     patients' subsequent course. Once the stigma of psychiatric
>>     disorder is appplied to an individual it can be impossible to
>>     remove it. Of 215 psychiatric patients in America, tests revealed
>>     that 41 percent should probably have not been referred in the
>>     first place, 63 percent had wholly treatable conditions. At a
>>     Manhattan psychiatric center, 131 patients selected at random were
>>     examined, and it was concluded that up to 75 per cent of them had
>>     been misdiagnosed when first admitted to the hospital. A principal
>>     error is to mistake signs of physical illness as emergent
>>     psychiatric problems. Instead of looking to practical remedies,
>>     which may be connected to lifestyle, emotional problems or some
>>     biochemical imbalance, the doctor prefers to lump what he does not
>>     understand under the heading of mental illness and thrust a
>>     patient into an institution, or put him on mind-altering drugs
>>     which may have irreversible effects.
>> >
>> >
>> >
>> > Dr Vikas Saini, a cardiologist and president of the Lown
>>     Institute, a healthcare think tank in Boston, is quoted by Reuters:
>> > “Most of what we do in medicine doesn’t have empirical evidence”
>>     for whether it works and for whom, said Saini. “Instead, it’s
>>     driven by anecdotal evidence and professional opinion,” which
>>     doctors who practice in the same area are likely to hear about and
>>     be influenced by, especially early in their careers.
>> >
>> >
>> > Victoria
>> >
>> > On 1/7/2014 10:49 PM, Alan Morris wrote:
>> >> Thank you.
>> >>
>> >> "A retrospective Isobel analysis detected my problem by my 20s."
>> >>
>> >>
>> >> This seems to be an anecdotal example of the value of
>>     decision-support
>> >> tools - particularly when the clinical problem is unusual or has an
>> >> unusual phenotypic expression.
>> >>
>> >> 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
>> >> e-mail:
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