[EXTERNAL] Re: [IMPROVEDX] quick ?

Pauker, Stephen SPauker at TUFTSMEDICALCENTER.ORG
Sun Apr 27 23:22:45 UTC 2014


To extend in a ToC framework re Change,
Measurements Drive Behavior 
so we need a proper measure
but to have one, it is likely necessary to
have a crisp (1 sentence) Goal Statement
to which we can measure progress
 
To Reduce/Eliminate Errors in Medicine Now and In The Future
 
may be overly simplistic, because it begs the eternal question: Why?
 
Steve
 
 
Stephen G. Pauker, MD, MACP, FACC, ABMH
Professor of Medicine and Psychiatry
===========================
Please note new email address;
spauker at tuftsmedicalcenter.org
===========================

________________________________

From: Swerlick, Robert A [mailto:rswerli at EMORY.EDU]
Sent: Sun 4/27/2014 4:03 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] [EXTERNAL] Re: [IMPROVEDX] quick ?



This is a very interesting discussion, which as far as I can tell started with Hardeep's article estimating the frequency of diagnostic errors in outpatient settings but has moved on to discussions of best approaches to reduce diagnostic error. I think the discussion should move back to where it started. 

 

That is because I believe that any discussion which weighs the options for improving diagnostic accuracy and avoiding diagnostic errors without being able to measure actual errors is not going anywhere. Yes, this task or sets of tasks will be very difficult and may appear at times to be impossible. But without the ability to measure diagnostic errors, all attempts to lessen numbers will be undertaken without knowing whether we are actually moving the needle or creating unintended problems. We have stories and stories are great for get attention and conveying a message. The next steps will require actual measurements and data  (ideally both numerators and denominators) of what is happening to patients. 

 

There are many different contexts where diagnostic errors may occur and different parties who might become aware that diagnostic error has possibly happened. Each of us brings very different life and clinical experiences to this discussion. The experience of the ED physicians is very different from that of the primary care doc, the patient with their own personal experience and presenting symptom complex v. the physician who has seen a sea of patients with a similar symptom complex, the hospital intensivist v. the community dermatologist. All likely experience, observe, commit diagnostic errors but there the similarities end. No single approach will work. 

 

Perhaps we need not only a definition of diagnostic error but also a taxonomy of diagnostic circumstances:

 

Inpatient v. outpatient

Acute disease v. chronic disease

Symptomatic disease v. asymptomatic (pre-disease) state

Life threatening v. non-life threatening (high stakes v. lower stakes)

Time constrained vs. not as time constrained

 

The tools we use under these different circumstances will be very different and the ability to measure will also depend on different clinical contexts. 

 

Bob 

 

 

Robert A. Swerlick, MD
Alicia Leizman Stonecipher Chair of Dermatology
Professor and Chairman, Department of Dermatology
Emory University School of Medicine
404-727-3669 
________________________________

From: Xavier Prida [dr.xavier.prida at gmail.com]
Sent: Sunday, April 27, 2014 2:06 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] [EXTERNAL] Re: [IMPROVEDX] quick ?


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 <mailto:apapier at logicalimages.com>  

 www.visualdx.com <http://www.visualdx.com/> 

www.skinsight.com <http://www.skinsight.com/> 

 Logical Images<https://webmail.tuftsmedicalcenter.org/Exchange/SPauker/Drafts/RE:%20[IMPROVEDX]%20[EXTERNAL]%20Re:%20[IMPROVEDX]%20quick%20_x003F_.EML/1_multipart/image001.png> 

	 

	 

	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 <http://www.visualdx.com/> 
	www.skinsight.com <http://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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	-- 

	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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