[EXTERNAL] Re: [IMPROVEDX] quick ?

Mittal, Manoj K MITTAL at EMAIL.CHOP.EDU
Sat Apr 26 22:00:12 UTC 2014


Just read this about decision making in a synopsis of a book,  "Average Is Over: Powering America Beyond the Age of the Great Stagnation" by Tyler Cowell, who writes mainly related to investing. He mentions 5 insights:

"Human strengths and weaknesses are surprisingly regular and predictable.
Be skeptical of the elegant and intuitive theory.
It’s harder to get outside your own head than you think.
Revel in messiness.
We can learn."

The refrain seems pretty similar to what we talk about - improving diagnosis in medicine:

1st point related to cognitive errors
2nd re our tendency to make up stories to explain events/premature closure
3rd about the difficulty of overcoming cognitive errors
4th about going slow; using Bayes' theorem to reach decisions; considering diagnoses with probabilities rather than as absolutes.
5th: what we are trying here!

Regards,
Manoj
________________________________________
From: Art Papier MD [apapier at logicalimages.com]
Sent: Saturday, April 26, 2014 5:21 PM
To: 'Society to Improve Diagnosis in Medicine'; Mittal, Manoj K
Subject: RE: [IMPROVEDX] [EXTERNAL] Re: [IMPROVEDX] quick ?

One of the common misperceptions is that diagnostic error always involves
rare diagnoses and therefore is really hard to study, another is that
prospective studies are not being performed.   Often very COMMON diagnoses
are missed due to premature closure, over confidence and other cognitive
reasons.  We looked at consecutive admissions for cellulitis at 2 major
teaching centers and showed that on average 28% of patients admitted for
cellulitis, did not have cellulitis
http://www.ncbi.nlm.nih.gov/pubmed/21426867  (also presented a poster on
this at DEM) a similar study in the UK showed the error rate to be 33%
http://www.ncbi.nlm.nih.gov/pubmed/21564054   Incredibly there are many
admissions for BILATERAL cellulitis in every city and town every day.  (for
the non-physicians on the list, cellulitis is a soft tissue infection, that
is 99.9% of the time only on one side of the body, usually the leg, but
hands, arms and other body parts occur..but not bilateral!) Dermatologists
have been grimacing, frowning, wringing their hands about this problem for
decades.  Ask pretty much any general medical dermatologist and you will get
the same puzzled response.  The academic dermatologists who cover the
inpatient consultation services all look like they are going to have a
seizure when you talk about this problem because it has been going on for
decades.  We are unsure why so many clinicians cannot diagnosis
lymphedema/stasis dermatitis in particular, but also common diseases like
gout, zoster, erythema nodosum, lyme disease and many other diseases that
are commonly called cellulitis.    Stasis dermatitis is the moist frequent
condition mis-diagnosed as cellulitis.   This single diagnostic error area
we estimate costs over 1.3 billion dollars in hospital admissions.  These
are potentially fixable mistakes.  The human cost includes giving health
people c. difficile or a life-threatening drug reaction such as Stevens
Johnson Or TEN to a person that did not need antibiotics, nor
hospitalization.   My hunch is there are many other problem areas where
diagnosis is led by the good old fashioned physical exam where misdiagnosis
thrives and is tolerated.  PS  Manoj-  admittedly this particular diagnostic
problem area is centered in adult medicine.

Art Papier MD
Chief Executive Officer
3445 Winton Place . Suite 240 . Rochester NY 14623
(585) 427-2790 x230 . apapier at logicalimages.com
 www.visualdx.com
www.skinsight.com



-----Original Message-----
From: Mittal, Manoj K [mailto:MITTAL at EMAIL.CHOP.EDU]
Sent: Saturday, April 26, 2014 3:40 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] [EXTERNAL] Re: [IMPROVEDX] quick ?

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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