[EXTERNAL] Re: [IMPROVEDX] quick ?

Mittal, Manoj K MITTAL at EMAIL.CHOP.EDU
Sat Apr 26 19:40:29 UTC 2014


Hi,

Thanks for your input.

I like Hardeep's framing of diagnostic errors as missed opportunities. It is important what labels we use.

Retrospective studies to identify diagnostic errors are a good start. The problem of hindsight bias in these studies, however, may make front line clinicians resistant to accept their conclusions.

I am a practicing PEM physician. Our practice has evolved to such an extent that new onset serious diseases (where improving diagnosis is most important as it can have a difference between life and death) have become very rare, be they serious sepsis/septic shock, bacterial meningitis (much less than 1 in 1000 children presenting with febrile illness), brain tumor, renal failure, etc. that any test (historical information and physical exam findings) has a very low positive predictive value.

We have to find a way to study diagnostic errors by prospective analysis of records. it is going to be difficult as all the records will have to be analyzed, but with the increasing use of EMRs and machine learning, it may become possible. The system could pick up suspect records that would be reviewed by the clinician's peers, who will decide if something was missed. The follow-up will show the truth. 

Thanks,
Manoj Mittal, MD
The Children's Hospital of Philadelphia
________________________________________
From: Graber, Mark [Mark.Graber at VA.GOV]
Sent: Saturday, April 26, 2014 2:00 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] [EXTERNAL] Re: [IMPROVEDX] quick ?

I'd like to underline the comment from David Gordon that .... "Ultimately, this evolving science about how to improve diagnostic efficacy is going to have to balance the harm that can come by both under and over diagnosis".  I couldn't agree more.

David was concerned that if we see an 'explosion' of research that focuses excessively on delayed and missed diagnoses, we will under-emphasize the harm from over-diagnosis.  I certainly acknowledge the costs and harm from over-diagnosis, but would argue that an explosion of studies on diagnostic error (under-diagnosis) is exactly what's needed right now to understand how to improve the efficiency and quality of diagnosis.

If there is going to be any explosion (doubtful, given that the funding for dx error research is almost nil at the moment) my bet will be that this will come from the over-diagnosis community.  The evidence for this is number of abstracts submitted to the Overdiagnosis Conference (in the hundreds) vs the Diagnostic Error in Medicine conference (a few dozen).  And the reason is that it is so much easier to study over-diagnosis - all the data has already been collected, and the extra CT's and incidentaloma's have all been tallied.  Finding and studying under-diagnosis is much harder, for all the reasons everyone has described.  It may take months or years to know that a diagnosis was missed and in many cases we may never know at all.

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