stroke misdiagnosis disproportionate in the young says Washington Post

Pat Croskerry croskerry at EASTLINK.CA
Sat Jun 21 00:47:00 UTC 2014


That's really the issue. Intuitive (Type 1) responses are usually the
default mode, and where most of our biases reside. Thus, cognitive biases
(cognitive dispositions to respond in a particular way) would be expected to
be strongest at the outset of an interaction with a patient -first
impressions are often the most powerful. The initial decision to engage a
decision rule (!) is really a Type 2 response, which entails cognitively
dis-engaging from one's intuitions. So, whether or not the rule is triggered
for that particular patient, will depend upon the mindfulness of the
clinician and their ability to reflect (metacognition). 

It seems likely that clinicians would be disinclined to engage a process
that is seen as redundant i.e this patient is clearly not the type who has a
stroke (unrepresentative of the class of stroke patients, and close to
stereotyping). Ian Stiell's group in Ottawa has done a lot of work looking
at why rules do not get used and it would be worthwhile to bring him into
this discussion.

If the decision rule contained defined age-limits explicitly including
younger patients then it might simply be a matter of emphasizing their
inclusion in the dissemination of the rule at the outset. 

Pat

 

 

From: David Newman-Toker [mailto:toker at JHU.EDU] 
Sent: Tuesday, June 17, 2014 7:24 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] stroke misdiagnosis disproportionate in the young
says Washington Post

 

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:  <mailto:toker at jhu.edu> toker at jhu.edu; 410-502-6270 (phone);
410-502-6265 (fax)
Web address:
<http://www.hopkinsmedicine.org/neurology_neurosurgery/specialty_areas/vesti
bular/profiles/team_member_profile/516F40C024FCA3D4B4B633D0E080FE1B/David_Ne
wman-Toker> Johns Hopkins Neurology (David Newman-Toker)

 


Confidentiality Notice: The information contained in this email is intended
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Thank you.

 

From: Pat Croskerry [mailto:croskerry at EASTLINK.CA] 
Sent: Tuesday, June 17, 2014 3:23 PM
To: 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
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-de
cline-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:  <mailto:toker at jhu.edu> toker at jhu.edu; 410-502-6270 (phone);
410-502-6265 (fax)
Web address:
<http://www.hopkinsmedicine.org/neurology_neurosurgery/specialty_areas/vesti
bular/profiles/team_member_profile/516F40C024FCA3D4B4B633D0E080FE1B/David_Ne
wman-Toker> Johns Hopkins Neurology (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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for Improving Diagnosis in Medicine

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  _____  



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for Improving Diagnosis in Medicine

To learn more about SIDM visit:
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