stroke misdiagnosis disproportionate in the young says Washington Post

Alan Morris Alan.Morris at IMAIL.ORG
Sat Jun 21 17:42:05 UTC 2014


Rob et al:
Education is commonly the traditional solution to our imperfections.  However, while it is important and leads to progress, it will not get us to our goals.  A recent publication in American J. of Infection Control. (State ofinfectionprevention in US Hospitals enrolled in the National Health and Safety Network.  2014;l42(2):94-9) regarding Central line associatedbloodstreaminfection, Hand hygiene at insertion was only practiced by an average of 62% of hospitals (range: 6-71% compliance).  We have been teaching hand hygienic for 10 decades.  I can think of not other compelling example of how far from our goals teaching leaves us.  Another example is provided by the Surviving Sepsis Campaign results (Levy et al. Int Care Med. 2010:36:222-31; Crit Care Med 2010; 38:367–374).  This campaign led to a 5.4% reduction in mortality (a laudable outcome).  However it was only able to increase compliance of clinicians with the sepsis bundle from 15 to 35%!  Hardly a compliance that would lead to a joyous celebration.

Education is clearly important.  However, education alone will not likely lead us to our goals of excellence.

Have  a nice day.

Alan H. Morris, M.D.
Professor of Medicine
Adjunct Prof. of Medical Informatics
University of Utah

Director of Research
Pulmonary/Critical Care Division
Sorenson Heart & Lung Center - 6th Floor
Intermountain Medical Center
5121 South Cottonwood Street
Murray, Utah  84157-7000, USA

Office Phone: 801-507-4603
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From: robert bell <rmsbell at ESEDONA.NET<mailto:rmsbell at ESEDONA.NET>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, robert bell <rmsbell at ESEDONA.NET<mailto:rmsbell at ESEDONA.NET>>
Date: Friday, June 20, 2014 at 9:57 PM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: [IMPROVEDX] stroke misdiagnosis disproportionate in the young says Washington Post

To me it seems as though we are not trained properly and that we need to completely change instruction in Medical Schools to a situation where we are repeatedly taught on simulators, to best practices and using computers extensively - all with high score pass expectations. Similar but different to the airline industry.

Currently, with the the complexity of medicine, the limited capacity of the human brain, the ever increasing volume of knowledge, the tendency, because of time restraints, to use work arounds, and to ignore best practices because no one can remember them, or even read them, we are not making any progress.

If we could get to situation where there was an intense attention to accuracy, this should flow over to not only Errors in Diagnosis but also Errors in Medicine as a whole. The current situation can well be characterized as a National disgrace.

This may not be the perfect suggestion, but let’s start trying something new?  Even if only on a trial basis somewhere. How long before things change? Any guesses.

Something needs to be done urgently it would seem?

Rob Bell




On Jun 20, 2014, at 5:47 PM, Pat Croskerry <croskerry at EASTLINK.CA<mailto:croskerry at EASTLINK.CA>> wrote:

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<mailto: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: 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>


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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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