Ideas on improving rates of missed/delayed diagnoses in PCP type visits.
jebrush at ME.COM
Mon Jan 20 03:19:17 UTC 2014
I think that the emphasis on “patient-centeredness” has largely focused on therapeutic decisions, and hasn’t adequately addressed diagnostic decision making. There needs to be more engagement. There are problems on both sides of the conversation. Many patients seem to seek the illusion of certainty. Some are biased by dread or wishful thinking. It is hard to be objective when you are the patient. All doctors are patients at some point, and know that they aren’t very good at diagnosing themselves.
I think it is a good idea to inform patients about the inherent uncertainty in diagnosis. I often ask patients “what do you think it is?” Sometimes I get a helpful answer. But usually, it least the question serves to get the patient thinking about the imprecision of testing and the difficulty in establishing a firm diagnosis.
I think there is one other lurking problem. The malpractice environment has a priming effect that can cause doctors to view patients and their families as potential litigants. Doctors can get defensive when patients ask questions about the diagnosis. Doctors need to recognize that this is usually irrational and they need to work on getting past that priming effect. Also, unfortunately, doctors visits are often too time-pressured to have a decent in-depth conversation.
There are a lot of barriers that inhibit getting patients better involved. It would be good to discuss the barriers and bring these impediments to doctor’s attention. I think the vast majority of doctors would like to learn how to better engage patients in diagnostic reasoning. I think helpful feedback and suggestions would be welcomed by virtually all physicians.
On Jan 19, 2014, at 6:22 PM, Vic Nicholls <nichollsvi2 at GMAIL.COM> wrote:
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?
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.
>>> 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
>>> 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
>>> > 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
>>> >> 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
>>> >> 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:
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