[EXTERNAL] Re: [IMPROVEDX] quick ?

Xavier Prida dr.xavier.prida at GMAIL.COM
Sun Apr 27 18:06:17 UTC 2014


Art,
      Superb elucidation of the need for combinatorial approaches.

And, would agree that decision trees/algorithms(of which any database and
software system would be comprised) require plasticity and "bailouts" to
allow for detection of, as you astutely described , atypical presentations
of common diseases(illness) as well as unknown and unrecognized(to the
examiner) hallmarks of either rare or common diseases(illness). Therefore,
one would not "be lead down the garden path" or distracted by "red
herrings".
The cognitive skill to which you refer is "chunking"- the ability to
aggregate, organize all data input(history, physical findings, testing) and
distill a short list or singular accurate diagnosis- can be inherent
extension of training, education, and experience with or without decision
support tools.

Also, telemedicine allows for "wisdom of the crowd"- collective cognition.

Xavier




On Sun, Apr 27, 2014 at 12:48 PM, Art Papier MD
<apapier at logicalimages.com>wrote:

> Xavier,
>
> System 1 thinking occurs well or not well depending on the level of
> expertise.  It is all in the cortex of the decision-maker, can they
> automatically recognize the pattern with a high degree of accuracy?
> Alternatively does someone who is not an expert, think they know the
> pattern, and automatically make a judgment and prematurely close on the
> wrong diagnosis?    Additionally, there is the possibility that the
> decision-maker was trained incorrectly and actually spends quite a bit of
> time thinking about the diagnosis (system 2), but comes to the wrong
> conclusion despite the strong effort.  Some clinicians just have the wrong
> understanding or knowledge of certain problems.
>
>
>
> What you describe is a potential remedy but in my over two decades of
> practicing medicine, I have never seen a clinician or resident use a
> decision tree. Logically a tree can cause a user to go down a path based on
> one confounding factor.  Combinatorial approaches just make more sense for
> complex decision making.   The decision making challenge of recognizing
> visual patterns is often very different than an internal medicine problem
> that requires exhaustive history, thorough physical exam and a thoughtful
> assessment.  It is as Malcolm Gladwell describes a “blink” moment.
>
>
>
> Not all chief complaints and problem domains are created equal.
>
>
>
> A patient presented to my office several years ago  and said something
> like this to our RN “I was  out hunting and I bent over and my scalp got
> scraped and now it is not healing”, but she was quite good and presents the
> patient to me with a shortened version of what the patient was saying , and
> an assessment   “he was out hunting and was scraped…. but he has a basal
> cell carcinoma and we need to set up for a biopsy”…….  The idea is that
> diagnosing a basal cell carcinoma is often 100% physical exam, no history
> necessary…my nurse made the diagnosis in a blink of an eye, knowing that
> the physical exam finding trumped the history…  most patients, believe that
> they are well and create histories to tell themselves that problems are
> minor….non system 1 experts for skin diagnosis, typically over rely on
> history.   Alternatively a patient with fever and a rash, and the rash is a
> morbilliform or exanthematous eruption then you likely need detailed
> history, exposures hx, travel hx etc.  Do they have Dengue because they
> went to South America?  Do they have a drug reaction? Which one?  Can you
> remember the questions to ask related to the presenting problem?
>
>
>
> So there is a framing that goes on , with some problems solved totally on
> a system 1 level and others that will always require system 2.
>
>
>
> I come back to my initial assertion and Bob’s question.   Yes telemedicine
> would be helpful, but these problems are so common that there would not be
> enough experts to be on the other end……we have hybridized telemedicine with
> decision support.  The decision support creates a training effect whereby
> the expert sends the referring doc through the (store and forward)
> telemedicine system a link into diagnostic decision support .  It saves the
> consultant dermatologist a ton of time because they do not have to write a
> long message.  Then the referring doc receives this clickable link and sees
> how they could have searched the diagnostic decision support system.  It is
> a “teaching someone how to fish model, instead of always fishing for
> them”.  We are doing this already in California in LA county and the VA
> system with great success.
>
>
>
> I must point out that there are so many confounding factors that an
> algorithm, matrix or checklist cannot possible cover all the variants.  The
> beauty of well-designed databases and software allows one to capture
> variation and push that back to the user.    I stand by my assertion that
> variants of commons often cause diagnostic error, not just rare birds.
>
>
>
>
>
> 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 <http://www.visualdx.com>*
>
> *www.skinsight.com <http://www.skinsight.com>*
>
> [image: Logical Images]
>
>
>
>
>
> *From:* Xavier Prida [mailto:dr.xavier.prida at gmail.com]
> *Sent:* Sunday, April 27, 2014 11:22 AM
> *To:* Society to Improve Diagnosis in Medicine; Art Papier MD
>
> *Subject:* Re: [IMPROVEDX] [EXTERNAL] Re: [IMPROVEDX] quick ?
>
>
>
> Art,
>
>      As to your stated example(cellulitis vs. stasis dermatitis), in our
> paradigm this would be a Type 1 error- cognitive("I didn't know that").
>  The remedy would be a decision matrix that excluded diagnosis of
> cellulitis if bilateral in description and defer to a diagnostic pathway
> including lymphedema/stasis dermatitis, e. nodosum, etc.
>
>
>
> Xavier
>
>
>
> On Sat, Apr 26, 2014 at 5:21 PM, Art Papier MD <apapier at logicalimages.com>
> wrote:
>
> 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.
>
>
>
>
>
>
> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society
> for Improving Diagnosis in Medicine
>
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> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society
> for Improving Diagnosis in Medicine
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> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society
> for Improving Diagnosis in Medicine
>
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> --
>
> Xavier E. Prida MD FACC FSCAI
>
> 813 813 0721(H)
>
> 813 245 3143(C)
>



-- 
Xavier E. Prida MD FACC FSCAI
813 813 0721(H)
813 245 3143(C)








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