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

Vic Nicholls nichollsvi2 at GMAIL.COM
Sun Jan 19 23:22:50 UTC 2014


Great post John.

In regards to, "Some patients are very engaged in their quest for a
diagnosis. How can we channel that motivation to help physician decision
making? How can we teach physicians to appropriately engage their
patients in a fruitful collaboration that results in better diagnosis?
Waiting for computers to take over medical diagnosis is a false hope.
Training every potential patient in diagnostic technique would be
impractical and impossible."

my questions are:

1) what is holding us back from doing that now?
2) how do you identify those patients that are engaged?
3) how can we get a relationship and collaboration for those of us that
aren't using Oprah as our references, when a lot of us get the
impression that the input is taken negatively personally?

Victoria


On 1/19/2014 4:52 PM, John Brush wrote:
> I think that the research needs to focus on improving the reliability
> of medical diagnosis. We need more research on measurement, because
> without accurate measurement, we can't assure reliability. IHI
> successfully did this for hospital based quality. The problem is that
> diagnostic encounters are hard to track, and the speed and accuracy of
> diagnosis are hard to measure. We need more than recognition and
> classification of errors. Without the denominator, we can't measure
> reliability.
>
> We already have some excellent research on the components of good
> diagnostic decision making. Some of these researchers are on this
> listserv. Our problem is that good decision making habits are not
> uniformly and consistently applied. We need more research on the
> implementation phase of medical decision making. What are the best
> ways to teach a reliable, consistent, and systematic approach to
> medical diagnosis?
>
> There are many people on this listserv from many different
> backgrounds. There are a lot of good ideas expressed, but it seems
> like we all have an oar in the water and we are all pulling in
> different directions. Seems like we could make more progress if we
> pulled in the same direction by acknowledging some common goals.
>
> I'll throw out a goal that will probably get strong reactions: Because
> the vast majority of diagnoses are currently, and will be in the
> foreseeable future, made by physicians, we should focus on how
> physician decision making can be improved and made more reliable. We
> need to focus on physicians. Computers are very reliable, so how can
> they be used in decision support to improve physician decision making?
> Some patients are very engaged in their quest for a diagnosis. How can
> we channel that motivation to help physician decision making? How can
> we teach physicians to appropriately engage their patients in a
> fruitful collaboration that results in better diagnosis? Waiting for
> computers to take over medical diagnosis is a false hope. Training
> every potential patient in diagnostic technique would be impractical
> and impossible. We need to focus on physicians, who society continues
> to entrust to make the vast majority of diagnoses. Medical trainees
> get less and less training in medical cognition, and we need to turn
> this around.
>
> I actually think that Larry Weed got this wrong in his recent book and
> commentary. Sure, some physicians deserve blame for sloppy thinking,
> but blaming physicians as a group for failed diagnosis is exactly the
> wrong thing to do. Our best hope for improvement is engaging
> physicians and improving their reliability through better education of
> good cognitive habits, through better support from technology, and
> through better collaboration with their patients.
>
> Just some thoughts...
> John Brush
>
> Sent from my iPad
>
> On Jan 19, 2014, at 10:27 AM, Robert Bell <rmsbell200 at YAHOO.COM
> <mailto:rmsbell200 at YAHOO.COM>> wrote:
>
>> We need much research. Evidence based diagnoses!
>>
>> I have been wondering if the creative thoughts of this list could
>> somehow be used to provide ideas for the the main areas that need
>> reasearch. Response rates might also give a rough idea of priority,
>> and what needs to be done first.
>>
>> Rob Bell
>>
>> Sent from my iPad
>>
>> On Jan 17, 2014, at 8:08 AM, Amy Reinert <amy.reinert at gmail.com
>> <mailto:amy.reinert at gmail.com>> 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 yahoo.com
>>> <mailto:rmsbell200 at yahoo.com>> 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
>>>     <mailto: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.
>>>     >
>>>     >
>>>     > http://www.medpagetoday.com/GarySchwitzer/43561
>>>     > 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 imail.org <mailto:alan.morris at imail.org>
>>>     >> e-mail:
>>>
>>
>> ------------------------------------------------------------------------
>>
>> <mailto:IMPROVEDX at LIST.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
>> <mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>
>>
>> Moderator: Lorri Zipperer Lorri at ZPM1.com <mailto: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
>
> 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 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>



More information about the Test mailing list