quick ?

John Brush jebrush at ME.COM
Wed Apr 30 02:05:18 UTC 2014


Hi Will,
I think that the elemental steps for making a diagnosis are constant, regardless of whether you are using an EMR, paper chart, dictating, typing, or using a scribe. And I agree that we work in an environment that has too many distractions that can interrupt our thought processes.
The transition to the EMR has been a disruption to our usual routines. But an EMR also makes it easier to retrieve important information and could be helpful in promoting a problem oriented approach.  Problem statements (provisional diagnoses) can be easily updated in the EMR in an iterative fashion as we go through the process of iterative hypothesis testing. Ultimately, I think that the EMR will improve our ability to make a correct diagnosis.
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 28, 2014, at 11:29 AM, Doctor Will <dr.will at fuse.net> wrote:

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)


-----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> 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> 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. [davidc.gordon at DUKE.EDU]
Sent: Friday, April 25, 2014 1:11 PM
To: IMPROVEDX at 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 delete it without further reading or retention. The information is not to be forwarded to or shared unless in compliance with Duke Medicine policies on confidentiality and/or with the approval of the sender.
From: Mittal, Manoj K [MITTAL at EMAIL.CHOP.EDU]
Sent: Friday, April 25, 2014 10:50 AM
To: IMPROVEDX at 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 [Eric.Thomas at UTH.TMC.EDU]
Sent: Friday, April 25, 2014 9:51 AM
To: IMPROVEDX at 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]
Sent: Thursday, April 24, 2014 11:15 AM
To: IMPROVEDX at 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
===========================
 

From: Danny Long [mailto:dannylong at EARTHLINK.NET]
Sent: Thu 4/24/2014 8:42 AM
To: IMPROVEDX at 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%29/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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