[EXTERNAL] Re: [IMPROVEDX] stroke misdiagnosis ... Washington Post [CB]

Graber, Mark Mark.Graber at VA.GOV
Tue Jun 24 17:45:52 UTC 2014


I'd like to hear  more from David Halibert on how using the PKC system is working out.  In particular, I'm interested in the theme that's been raised in this discussion regarding the 'optional' use of decision support products, where you'd lose the power to detect the rare-but-important 'don't miss' diagnoses?


 *   How many practices are using PKC's?
 *   What is the time investment for the patient and the provider?
 *   How does the support for differential diagnosis compare to systems specifically designed for that purpose (DXplain, Isabel?)
 *   Is it used in every case?
 *   Would it have suggested the possibility of stroke in a young patient with headache?

Mark

Mark L Graber MD FACP
President, SIDM
________________________________
From: David Hallbert <david.hallbert at GMAIL.COM>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, David Hallbert <david.hallbert at GMAIL.COM>
Date: Mon, 23 Jun 2014 21:46:04 -0400
To: <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [EXTERNAL] Re: [IMPROVEDX] stroke misdiagnosis ... Washington Post [CB]

   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

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-------- Original Message --------
Subject: Re: [IMPROVEDX] stroke misdiagnosis disproportionate in the
young says Washington Post
From: David Newman-Toker < <mailto:toker at JHU.EDU> toker at JHU.EDU>
Date: Tue, June 17, 2014 6:23 pm
To:  <mailto: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 <mailto:toker at jhu.edu> ; 410-502-6270 <tel:410-502-6270>  (phone); 410-502-6265 <tel: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> mailto:croskerry at EASTLINK.CA]
 Sent: Tuesday, June 17, 2014 3:23 PM
 To:  <mailto: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 [ <mailto:toker at JHU.EDU> mailto:toker at JHU.EDU]
 Sent: Tuesday, June 17, 2014 3:56 PM
 To:  <mailto: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 <mailto:toker at jhu.edu> ; 410-502-6270 <tel:410-502-6270>  (phone); 410-502-6265 <tel: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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