quick ?

Doctor Will dr.will at FUSE.NET
Mon Apr 28 15:29:37 UTC 2014


Good morning John et al,

Thank you. Then the clinician is expected to "type" the raw data into
multiple screens and drop down boxes and expected to examine the patient
thoroughly as well as previous data from the EMR and patient, make eye
contact with the patient, (and answer a page/call if a hospitalist) and "be
productive", complete hand hygiene etc.

So a scribe (data input administrative assistant ?) could be extremely
helpful (particularly ED and PCPs) in completing pure administrative tasks,
search and collate previous data and perhaps help initiate decision support
when needed.  Now that is true team work leading to better patient outcomes.

And if this type of team work MAY lead to clinicians deciding to stay in
practice longer, instead of looking for the exit, as is happening these past
two years.

Yes we can create a better (safer) patient care system if we "think it"
different.

Will Sawyer, MD

Dr.will at henrythehand.org 

513-769-4951

 

  _____  

From: John Brush [mailto:jebrush at me.com] 
Sent: Sunday, April 27, 2014 5:05 PM
To: Doctor Will
Cc: Society to Improve Diagnosis in Medicine
Subject: Re: [IMPROVEDX] quick ?

 

Will,

I'll take a shot at addressing your question by first restating the
question: How can a hospitalist maximize the chances of a correct a
diagnosis?

By consistently and systematically going through a series of logical steps. 

1. Take a thorough history and perform a careful exam to establish an
initial database. 

2. Early hypothesis generation to target your questions and the initial
evaluation.

3. Begin to transform the patient's history and findings into a coherent
narrative.

4. Develop a short differential diagnosis.

5. Use iterative hypothesis testing to sort through diagnostic possibilities
and to narrow the field of leading hypotheses.

6  Judicious use of testing and consultation to generate additional
information.

7. Appropriately weight each new piece of information. Experienced
clinicians will have an intuitive sense and less experienced clinicians can
use likelihood ratios to give each piece of new information the proper
weight.

8. By using a likelihood ratios, either explicitly or implicitly, the
clinician is led to also consider prior probabilities, which will help to
avoid base-rate neglect.

9. Decide on the most likely diagnosis and use causal reasoning as a double
check for plausibility (abductive reasoning).

10. Define the diagnosis with a problem statement that is as specific and
explicit as possible.

11. Confirm the diagnosis with further testing or perhaps a therapeutic
trial.

12. Keep the patient informed and seek the patient's input and feedback as
you progress through the steps and begin to reach conclusions.

 

Just my thoughts. I'm sure there are many on this listserv who can improve
on my method. I think this "off the top of my head" list of steps
demonstrates how complicated the diagnostic process can be.  And the process
is different for other specialties and in other settings. Making a correct
diagnosis isn't easy, but diagnosis is what is most challenging and
rewarding about medicine, in my view.

John

 

 

On Apr 27, 2014, at 3:48 PM, Doctor Will <dr.will at fuse.net> wrote:

 

Hello John et al,

So can someone define the roles and duties of the clinician to facilitate
limiting diagnostic (and patient) errors for the hospitalist in this case?
Describe their tasks when seeing each patient. I "see" an elephant in the
room but no one has mentioned it yet.

Will Sawyer, MD

Cincinnati, Ohio

Dr.will at henrythehand.org 

513-769-4951 (O)

 

  _____  

From: John Brush [mailto:jebrush at ME.COM] 
Sent: Sunday, April 27, 2014 1:40 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] quick ?

 

            I have been following this conversation and I continue to
believe that our best way to improve diagnosis in medicine is to teach good
habits. Teach people to be systematic, to appropriately use the available
tools, and to calibrate their intuitive approaches with better numerical
literacy and probability estimates.  Focusing on errors doesn't seem like a
very fruitful path forward.

            Anecdotes and patient stories can motivate us to improve, but
don't necessarily give us the lessons on how to improve. And measuring
diagnostic error rates will always be difficult in the real world. No doubt,
the studies that have estimated the error rates are important for raising
public awareness and motivating our efforts. Diagnostic errors occur way too
commonly. But measuring diagnostic error rates will be always be problematic
for analysis of individual performance over time. Effective practitioners
seek follow up, measurement and feedback for internal use, but external
reporting of error rates could have lots of unintended consequences.

            Measuring diagnostic skill is like measuring fielding in
baseball. Baseball uses fielding percentages, but we know that that measure
is flawed. A player can improve his fielding percentage by limiting his
range. Likewise, a hospitalist can lower his/her error rate by consulting on
every patient and ordering lots of tests, which in effect limits his/her
range and is very inefficient. And certain positions, like first base, have
a better chance of getting a higher fielding percentage. Likewise, certain
medical specialties have a better chance of avoiding diagnostic error than
others. Also, to measure fielding percentage, you have to track every single
opportunity, which is virtually impossible in clinical medicine. This email
string is a testament to the difficulties in defining errors and tracking
opportunities.

            So, in my humble opinion, we need to focus on education efforts,
to help practitioners and patients develop better diagnostic habits, and
facilitate the consistent use of these good habits.

John

 

John E. Brush, Jr., M.D., FACC

Professor of Medicine

Eastern Virginia Medical School

Sentara Cardiology Specialists

844 Kempsville Road, Suite 204

Norfolk, VA 23502

757-261-0700

Cell: 757-477-1990

jebrush at me.com

 

 

 

On Apr 26, 2014, at 12:30 PM, Pauker, Stephen
<SPauker at tuftsmedicalcenter.org> wrote:

 

Let me extend Kassirer's thought perhaps. Allow me to suggest, depending on
definitions, that our quest for being free of diagnostic errors is similarly
stubborn and may sometimes be unattainable, when diagnostic uncertainty
still exists at a given point of time
Steve



Sent with Good (www.good.com <http://www.good.com/> )


-----Original Message-----
From: Gerrit Jager [gerrit.jager at PLANET.NL]
Sent: Saturday, April 26, 2014 11:11 AM Eastern Standard Time
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] quick ?

Indeed, it get complex. The discussion started  about the definition of
diagnostic errors.

I like the word "error"  ("errare",  wandering from the truth, even if the
truth may be unknown")   In our language (Dutch) we use the negative verbs
misses and faults.

The words of Jerome Kassirer "Absolute certainty in diagnosis is
unattainable, no matter how much information we gather, how many
observations we make, or how many tests we perform." (Our Stubborn Quest for
Diagnostic Certainty, N Engl J Med 1989) are still up-to-date.
We are often wrong for the right reason.

If possible, It will be very challeging to define the line between "no
fault" diagnostic errors and preventable errors.

Gerrit

Gerrit Jager
Radiologists
The Netherlands
 


Op 25-04-14 22:46, robert bell <rmsbell at ESEDONA.NET
<x-msg://15/rmsbell@ESEDONA.NET> > schreef:

David, Edward,

Agree, and this also tied to cost effectiveness, which in turn is linked to
services available - there may not even be a CT scanner available.

Doesn't it get complex?

Rob


On Apr 25, 2014, at 12:34 PM, Hoffer, Edward P.,M.D.
<EHOFFER at MGH.HARVARD.EDU <x-msg://15/EHOFFER@MGH.HARVARD.EDU> > wrote:

Excellent point, to which I would like to add that Dr. A will find all sorts
of "incidentalomas" on the CT scans, which will require FURTHER testing,
most of no avail to the patient.
 

Ed
Edward P Hoffer MD, FACC, FACP

  _____  

From: David Gordon, M.D. [ <x-msg://15/davidc.gordon@DUKE.EDU>
davidc.gordon at DUKE.EDU]
Sent: Friday, April 25, 2014 1:11 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
<x-msg://15/IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG> 
Subject: Re: [IMPROVEDX] quick ?

I am SO GLAD to see Eric's and Manoj's comments appear because they
highlight a really important piece of the puzzle.

If all we focus on is the miss or delay rate, we will fail to appreciate the
harm that can come by over diagnosis and over treatment. Take a theoretical
and extreme example for illustrative purposes:
--Doctor A obtains a CT scan on every patient with RLQ pain across the board
to make sure appendicitis is not missed. Still may miss a case or 2 over the
course of several years due to the intrinsic miss rate of CTs
--Doctor B does a selective approach. Using his judgment and sometimes
guided by labs, he sometimes will do a CT, sometimes will recommend a
clinical recheck the next day, or sometimes tells the patient everything
looks fine today and come back as needed for worsening.  In doing this, he
may miss a few more cases of appendicitis over the years than Doctor A but
avoids hundreds of unnecessary CT scans.

So if the only variable studied is how often a diagnosis is missed, Doctor A
will always come out on top when in the more complete picture his
overtesting and overtreating style can lead to greater public harm not only
through greater cost but also through radiation exposure, adverse medication
reactions, drug resistance, and so on.  

I am sure we are going to see an explosion of studies looking at how often
diagnoses are missed or delayed. I gather the majority will be retrospective
studies - at least in these early phases. My fear is that retrospective
analysis has many limitations and unmeasured variables, yet it is going to
be the results rather than the limitations that will receive greater public
attention. 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 hope the caution expressed by Eric that we are a long
way from safely implementing performance metrics and regulations is heard
widely and embraced strongly.

Thanks
David




David Gordon, MD
Associate Professor
Undergraduate Education Director
Division of Emergency Medicine
Duke University

The information in this electronic mail is sensitive, protected information
intended only for the addressee(s). Any other person, including anyone who
believes he/she might have received it due to an addressing error, is
requested to notify the sender immediately by return electronic mail, and to
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  _____  

From: Mittal, Manoj K [ <x-msg://15/MITTAL@EMAIL.CHOP.EDU>
MITTAL at EMAIL.CHOP.EDU]
Sent: Friday, April 25, 2014 10:50 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
<x-msg://15/IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG> 
Subject: Re: [IMPROVEDX] quick ?

Thanks, Eric.
That is a useful definition.
What concerns me a little bit is that we are labeling events as diagnostic
errors based on retrospective review of the chart. This may lead to
over-diagnosis of diagnostic errors.

It is far easier to see something as a missed opportunity when one knows the
future.
When you are with a patient in the office or in the emergency department,
though, and the case is not straightforward, there may be some pointers to
the final diagnosis, but the trick is to find the signal amongst all the
noise.

It will be useful to test the various differential diagnosis list
generators, such as Isabel, prospectively, to see how much they help, and at
what cost (in terms of increased testing, imaging, increasing LOS, false
positive tests, etc.).

Regards,
Manoj Mittal, MD

  _____  

From: Thomas, Eric [ <x-msg://15/Eric.Thomas@UTH.TMC.EDU>
Eric.Thomas at UTH.TMC.EDU]
Sent: Friday, April 25, 2014 9:51 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
<x-msg://15/IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG> 
Subject: Re: [IMPROVEDX] quick ?

Steve and Colleagues,

In some of the research I have done with Hardeep Singh, we have tried to use
definitions of diagnostic errors that allow a reliable and valid measurement
to occur.  We mostly avoided the issue of diagnoses that evolve over time.  

In some of our work we used the following definition, "An error was judged
to have occurred if adequate data to suggest the final, correct diagnosis
were already present at the index visit or if the documented abnormal
findings at the index visit should have prompted additional evaluation that
would have revealed the correct, ultimate diagnosis.  Thus, errors occurred
only when missed opportunities to make an earlier diagnosis occurred based
on retrospective review."  The "index visit" is the visit we sampled for
review.  I won't get into all the details here, but this definition was used
for a study where we sampled primary care visits which preceded an
unexpected return visit to the primary care office or the ED.

So, when that definition is used we are pretty much eliminating the cases
that are evolving over time.  We called it a dx error when all the data was
there at the time of the visit to make the right dx.  As a practicing
primary care doc, I am very sensitive to the fact that diagnoses evolve over
time and it is often unclear what the dx is at the time of a single visit.
Our research does not label delays when all the data is not available as an
error.

I agree with others that we will never know THE rate of diagnostic error.
However, with good measurement we can come to understand the frequency,
types, and contributing factors of dx error within certain practice settings
and for certain diseases.  I think a disease-specific and setting-specific
approach will lead to the most improvement.

While I have your attention (wishful thinking, I know) I'd also say that we
are a very, very long way from measures of dx error that could be useful for
any external body (CMS, Leapfrog, etc) to use as some type of publically
reported performance measure.  Groups like that have already gone too far
with efforts to measure safety - in many organizations those externally
mandated, top-down measures create cultures of accountability and even blame
such that caregivers end up redefining or even hiding events so they don't
have to be reported to management.  Also, those externally mandated measures
only capture a small fraction of all the harm that occurs.  What we need,
especially for diagnostic errors, are cultures where learning and
improvement are valued.  Externally mandated measures, especially those not
based on good science, will not help us reduce diagnostic errors.

Best,

Eric

Eric J Thomas MD, MPH
Professor of Medicine
Associate Dean for Healthcare Quality
Director, UT Houston-Memorial Hermann Center for Healthcare Quality and
Safety
The University of Texas Medical School at Houston
6410 Fannin UPB 1100.44
Houston, TX 77030
713-500-7958
www.utpatientsafety.org <http://www.utpatientsafety.org/>

 
 

From: Pauker, Stephen [ <mailto:SPauker at TUFTSMEDICALCENTER.ORG>
mailto:SPauker at TUFTSMEDICALCENTER.ORG]
Sent: Thursday, April 24, 2014 11:15 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
<x-msg://15/IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG> 
Subject: Re: [IMPROVEDX] quick ?


Patient care and diagnoses evolve over time as things are revealed.
So labeling something as a diagnostic error depends on when in
the patient's course it's measured. In the course of disease evolution,
the primary diagnosis can change. So perhaps we should not make a diagnosis
ever but say "At this moment I think the probability of X is P". Of course,
the evolving issue is
when to treat or test with what modalities.


Steve


Stephen G. Pauker, MD, MACP, FACC, ABMH
Professor of Medicine and Psychiatry
===========================
Please note new email address;
spauker at tuftsmedicalcenter.org <x-msg://15/spauker@tuftsmedicalcenter.org> 
===========================

 

  _____  


From: Danny Long [ <mailto:dannylong at EARTHLINK.NET>
mailto:dannylong at EARTHLINK.NET]
Sent: Thu 4/24/2014 8:42 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
<x-msg://15/IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG> 
Subject: Re: [IMPROVEDX] quick ?

When cover-up is the standard of care, who really knows the facts besides
the ones doing the cover-up? The underlying motivation to nearly end
autopsies.. just the truth.
Statistics
Errors related to missed or delayed diagnoses are a frequent cause of
patient harm. In 2003, a systematic review of 53 autopsy studies from 1966
to 2002 was undertaken to determine the rate at which autopsies detect
important, clinically missed diagnoses. Diagnostic error rates were 4.1% to
49.8% with a median error rate of 23.5%.* Furthermore, approximately 4% of
these cases revealed lethal diagnostic errors for which a correct diagnosis
coupled with treatment could have averted death.4 Other autopsy studies have
shown similar rates of missed diagnoses; one study reported the rate to be
between 10% to 12%5, while another placed it at 14%.6 Autopsies are
considered the gold standard for definitive evidence of diagnostic error,
but they are being performed less frequently and provide only retrospective
information.


http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2010/Sep7%283%2
9/Pages/76.aspx


Knowing the CDC are well aware death certificates are often falsified...
even the Joint Commission are against autopsies .. so the prevailing logic
is, keep the facts blurry and the conversation of how bad is the problem
will keep the public in the dark. and make correcting the diagnosis problem
nearly impossible to do anything about.  = keep the excuses alive.


 

:-( garbage in garbage out to keep the data corrupt.

 

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