stroke misdiagnosis ... Washington Post [CB]

David Hallbert david.hallbert at GMAIL.COM
Tue Jun 24 01:46:04 UTC 2014


   I'd be interested in hearing more about this.  In our practice for years
we've used Lawrence Weed's PKC.  Patients are asked to enter their symptoms
by answering an extensive set of relevant questions about a given syptom
into a computer so that their input gets heard first before the physician
gets to form his initial opinion and thereafter guide the discussion to
positives and negatives that support his hypothesis. (discussed in Dr
Groopman's book, "How Doctors Think").   The computer "couples" the
information and tallies "points" in favor of this or that diagnosis.  The
physician gets to review the options and refine their meaning with the
patient, but then looks over ALL the results and adds indicated elements of
the physical exam (guided by the computer).  With the patient in
collaboration they review the findings that may go with each possible
explanation for their symptoms--the pros and cons for each diagnosis with a
link to the medical literature for each possibility.  They would together
be forced to confront the possibility and all the supporting evidence for
stroke--even in a younger patient--before accepting or rejecting that
hypothesis.  They may also review management options guided by this
software program. I think this method jibes much more closely to solving
the inherent problem of the human brain alone outlined in Daniel Kahneman's
book, "Thinking Fast, Thinking Slow" in that it uses the computer to do a
much better job at what it does best--combing the vast amount of medical
literature to generate possibilities-- and leaves humans to use their
intuitive senses for iterative work.  I read Clive Thompson's book,
"Smarter Than You Think" and see a parallel with the superiority of human
plus computer over either one alone in major chess competitions.


On Sun, Jun 22, 2014 at 9:11 AM, Robert Bell <
0000000296e45ec4-dmarc-request at list.improvediagnosis.org> wrote:

> That sounds that using computers that have more power. RB
>
> Sent from my iPad
>
> On Jun 19, 2014, at 6:42 AM, Charlie Garland - The Innovation Outlet<
> cgarland at INNOVATIONOUTLET.BIZ> wrote:
>
> 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
>
> =================================================
>
> Charlie Garland, President
>
> *The Innovation Outlet*
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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>toker at JHU.EDU>
> Date: Tue, June 17, 2014 6:23 pm
> To: <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> 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; 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
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> email message. Thank you.
>
>   *From:* Pat Croskerry [ <croskerry at EASTLINK.CA>
> mailto:croskerry at EASTLINK.CA <croskerry at EASTLINK.CA>]
> *Sent:* Tuesday, June 17, 2014 3:23 PM
> *To:* <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> 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 [ <toker at JHU.EDU>mailto:toker at JHU.EDU
> <toker at JHU.EDU>]
> *Sent:* Tuesday, June 17, 2014 3:56 PM
> *To:* <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> 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>
> 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>
> 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; 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
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> dissemination, distribution, or copying of this communication is strictly
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>
>
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