stroke misdiagnosis ... Washington Post [CB]

Mahajan, Prashant PMahajan at DMC.ORG
Thu Jun 19 13:59:14 UTC 2014


Dear All,
Semi-pertinent article related to how a woman recorded her stroke to convince providers
http://www.foxnews.com/health/2014/06/19/selfie-womans-mini-stroke-helps-doctors-make-diagnosis/

I do not mean to steer this conversation but great example and a reminder that newer diagnostic tools, CDR etc should include the patients - most CDRs are remote and seem academic - difficult to apply in real time and often do not take clinician suspicion into consideration (which along with legal implications, I suspect, are largely the reason for non-compliance with pathways)

Best
Prashant


Prashant Mahajan MD MPH MBA
Division Chief and Research Director
Pediatric Emergency Medicine
Professor of Pediatrics & Emergency Medicine
Director Center for Quality and Innovation
Carman & Ann Adams Department of Pediatrics
Children's Hospital of Michigan
Detroit, MI - 48201
Phone: 313-745-5260
Fax: 313-993-7166
Email: pmahajan at dmc.org and mahajan at comcast.net
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________________________________
From: Charlie Garland - The Innovation Outlet [mailto:cgarland at INNOVATIONOUTLET.BIZ]
Sent: Thursday, June 19, 2014 9:42 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] stroke misdiagnosis ... Washington Post [CB]

David (and Pat) - It is my opinion -- as a non-physician, but as someone with some expertise in anthropology and cognitive biases -- that we do, indeed, have a problem larger than most have imagined.  One of the issues you're referencing here is a physician's use of critical thinking, which may equate to their disposition to access meta-cognition.  This is a dynamic that I refer to as "cognitive buoyancy" -- the propensity (disposition) to raise one's level of conscious awareness and consideration of process, condition, context, and subsequent alternative choices (in real time), above the routine.  This may be a natural inclination in some; in others, it may require one or more stimuli (visual, audible, cognitive, rules-based, etc.) to elicit the cognitive-buoyancy response.

Neuroscience tells us that the brain is an energy-miserly organ -- it naturally functions, in part, to conserve its constrained energy resources.  Higher-order cognitive functioning (i.e. "executive reasoning," critical thinking, metacognition, etc.) require significantly more energy than the "hard-wired" routines that we assimilate by default, thanks to the brain's constant bias toward lower-energy processing.  So the default state of our minds (physicians included) is one of rote, un-conscious functioning.  Admittedly, medical training, certain CME, clinical practice, and hospital policy/culture do, themselves, tend to increase all healthcare providers' cognitive buoyancy.  But not sufficiently.  That's one reason where/why we have a much larger problem (in my opinion).

There are a number of resources we might look to, as ways of increasing cognitive buoyancy.  Some may include increasing those factors mentioned above, but my own research includes the utilization of a set of tools and methodologies that can be used to raise this disposition in clinicians (and others).  The tools are designed specifically to both trigger, and then help guide, an individual's metacognition...which then leads to consideration of alternative (non-routine) choices for subsequent contemplation and/or action.  It is at this point where a physician might be reminded of the existence/appropriateness/need of such CDRs, or other available resources that hadn't otherwise come to mind.

If this makes sense, and you would be interested to learn more details about what I am referring to, I'd be happy to elaborate further about the tool ("Cubie"), the methodology ("Explorative Inquiry"), and the state of my research.

Kind regards,
Charlie Garland

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-------- Original Message --------
Subject: Re: [IMPROVEDX] stroke misdiagnosis disproportionate in the
young says Washington Post
From: David Newman-Toker <toker at JHU.EDU<mailto:toker at JHU.EDU>>
Date: Tue, June 17, 2014 6:23 pm
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>

I agree, Pat. Do you (or others) think that clinicians are also less likely to use (or think of using) clinical decision rules related to stroke (e.g., Ottawa SAH rule or HINTS) in those same patients? If so, do we have an even bigger problem than we imagined --- i.e., that even if we convince people to 'routinely' use evidence-based diagnostic decision rules for stroke (or other similar diagnostic problems where errors are more frequent than we'd like), that their cognitive dispositions to respond will lead to selective non-use of these rules in more atypical (i.e., less representative) cases?
David
David E. Newman-Toker, MD, PhD
Associate Professor, Department of Neurology
Johns Hopkins Hospital, Meyer 8-154; 600 North Wolfe Street, Baltimore, MD 21287
Email: toker at jhu.edu<mailto:toker at jhu.edu>; 410-502-6270 (phone); 410-502-6265 (fax)
Web address: Johns Hopkins Neurology (David Newman-Toker)<http://www.hopkinsmedicine.org/neurology_neurosurgery/specialty_areas/vestibular/profiles/team_member_profile/516F40C024FCA3D4B4B633D0E080FE1B/David_Newman-Toker>

Confidentiality Notice: The information contained in this email is intended for the confidential use of the above named recipient. If the reader of this message is not the intended recipient or person responsible for delivering it to the intended recipient, you are hereby notified that you have received this communication in error, and that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this in error, please notify the sender immediately by telephone at the number set forth above and destroy this email message. Thank you.
From: Pat Croskerry [mailto:croskerry at EASTLINK.CA]
Sent: Tuesday, June 17, 2014 3:23 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] stroke misdiagnosis disproportionate in the young says Washington Post
Probably a number of factors involved, but principle among them are likely to be representativeness and ascertainment biases.
i.e. clinicians see what they expect to see, and expect stroke victims to be older.
Pat
From: David Newman-Toker [mailto:toker at JHU.EDU]
Sent: Tuesday, June 17, 2014 3:56 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] stroke misdiagnosis disproportionate in the young says Washington Post
Stroke is a major public health problem, and recent work suggests young patients are having more strokes, with rates rising alarmingly in recent years, according to an article in today's Washington Post...
http://www.washingtonpost.com/national/health-science/strokes-long-on-the-decline-among-the-elderly-are-rising-among-younger-adults/2014/06/16/f1f54538-e5d9-11e3-a86b-362fd5443d19_story.html
They are also much more likely to be misdiagnosed (7-fold greater risk in those 18-45 relative to those >75)...
http://www.degruyter.com/view/j/dx.2014.1.issue-2/dx-2013-0038/dx-2013-0038.xml
Thoughts?
David
David E. Newman-Toker, MD, PhD
Associate Professor, Department of Neurology
Johns Hopkins Hospital, Meyer 8-154; 600 North Wolfe Street, Baltimore, MD 21287
Email: toker at jhu.edu<mailto:toker at jhu.edu>; 410-502-6270 (phone); 410-502-6265 (fax)
Web address: Johns Hopkins Neurology (David Newman-Toker)<http://www.hopkinsmedicine.org/neurology_neurosurgery/specialty_areas/vestibular/profiles/team_member_profile/516F40C024FCA3D4B4B633D0E080FE1B/David_Newman-Toker>

Confidentiality Notice: The information contained in this email is intended for the confidential use of the above named recipient. If the reader of this message is not the intended recipient or person responsible for delivering it to the intended recipient, you are hereby notified that you have received this communication in error, and that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this in error, please notify the sender immediately by telephone at the number set forth above and destroy this email message. Thank you.
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