[EXTERNAL] Re: [IMPROVEDX] quick ?

Pauker, Stephen SPauker at TUFTSMEDICALCENTER.ORG
Mon Apr 28 16:43:37 UTC 2014


I must respectfully disagree and ask that we be sure to define our terms. When I use the term decision tree I mean a representation of outcomes, probabilities, and choices. I think you are thinking of a graphic algorithm, but in my experience many of us use them when we see problems outside our regular comfort zone of experience. Greenfield and others showed many years ago that the help.

In our shop at Tufts, we teach the principles of decision analysis and apply them (sometimes as consultants) when the going gets tough. If you have never found then helpful, perhaps the demographics of your practice restrict you to the simple or patients who do not require System 2 thought.

I would respectfully suggest that dissing or discounting an entire approach that many have found useful is perhaps a great example of premature closure--a well known cognitive error.

By the way I have been practicing for over 40 years.

Steve



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-----Original Message-----
From: Art Papier MD [apapier at LOGICALIMAGES.COM]
Sent: Sunday, April 27, 2014 12:55 PM Eastern Standard Time
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] [EXTERNAL] Re: [IMPROVEDX] quick ?



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

www.skinsight.com



 

 

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 <tel:%28585%29%20427-2790%20x230>  . 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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--

Xavier E. Prida MD FACC FSCAI

813 813 0721(H)

813 245 3143(C)


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