Diagnostic Error as Major Issue in Healthcare reported in ECRI and ASHRM Today

Bruno, Michael mbruno at HMC.PSU.EDU
Mon Aug 18 14:36:37 UTC 2014

Dear Victoria, Pat and ListServ group,

There is another component of this ‘evidence-based’ problem that is very much worth considering—the biases inherent in the way that scientific data are published (or not) which impacts strongly on the reliability of the results upon which we depend.  See the attached essay, from PLOS Medicine published nine years ago, entitled “Why Most Published Research Findings are False.”*   Many doctors and even some scientists seem to have a fundamental misunderstanding of what “statistical significance” actually means, and the non-publication (and usually non-publishability) of so-called “negative results” are key factors.  Of course, one of the basic assumptions in all forms of scientific research, including biomedical research, is that the findings should be replicable / replicated independently—which should identify such false results and purge the errors—but due to limitations in research resources and funding no attempt is ever made to replicate the majority of reported studies.  Thus, false beliefs are readily incorporated into our cannon.

While computers have some promise to improve on diagnoses based on human memory and human cognitive biases as Art has pointed out, one must remember that they provide no help if the underlying “information” upon which the technology acts is incorrect.  The simplest and most profoundly accurate statement I’ve ever heard regarding computers is still: “Garbage in = Garbage out.”

All the best,

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Michael A. Bruno, M.D., F.A.C.R.
Professor of Radiology & Medicine
Director of Quality Services & Patient Safety
The Milton S. Hershey Medical Center
Penn State College of Medicine
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Hershey, PA  17033

Phone: (717) 531-8703
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e-mail: mbruno at hmc.psu.edu<mailto:mbruno at hmc.psu.edu>

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*The URL for this essay is: http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.0020124

From: Vic Nicholls [mailto:nichollsvi2 at GMAIL.COM]
Sent: Saturday, August 16, 2014 10:01 PM
Subject: Re: [IMPROVEDX] Diagnostic Error as Major Issue in Healthcare reported in ECRI and ASHRM Today


You said correctly. I have found that by thinking the way through medical research, it gives a very clear picture. The problem is that there is a lot of memorizing in medicine, you rely on it, rather than the ability to think the different pieces through. It would help because people like myself who do go to doctors and have to think our way through problems at work and home, doctors don't tend to like our questions.

Nor that we think thru research.


On 8/16/2014 5:06 PM, Pat Croskerry wrote:
Agreed that a major transition is going on in medicine. Much of it good – immediately accessible knowledge at the touch of a button and less reliance on the fallibilities of human memory. But studies on diagnostic failure show that knowledge deficits are not the major issue – it is how clinicians think about diagnosis. The complexity of the interface with the patient is invariably underestimated and to imagine that computers will be a panacea is wishful at best. At worst, increasing dependency on mobile technologies by off-loading cognitive operations will likely compound our problems. There is a distinction to be made between those who are ‘uncomfortable’ with computers and those who can appreciate the unintended consequences of over-reliance on technology.

In the good old days, I don’t recall ever being taught about decision making and how bias could affect my clinical judgment – certainly there was no mention of ‘cognitive debiasing’. These are all fairly recent innovations. The evidence is now very clear that dramatic improvements in problem solving can be achieved using critical thinking training. More than ever before, we need to be graduating physicians who can think critically – it won’t be the answer to all the problems in diagnostic failure, but it will help in a significant way.


From: Art Papier [mailto:apapier at LOGICALIMAGES.COM]
Sent: Thursday, August 14, 2014 10:21 PM
Subject: Re: [IMPROVEDX] Diagnostic Error as Major Issue in Healthcare reported in ECRI and ASHRM Today

Mike- Also another liability company is engaged and moving on diagnostic errors with innovative programs.  Coverys, a Boston headquartered liability company is offering a liability premium discount to those insured physicians that they insure to use VisualDx diagnostic CDS.  Coverys has also certified VisualDx for point-of-care CME.  Geri Amori, PhD, ARM, CPHRM, DFASHRM, Vice President, Academic Affairs for Coverys will be attending DEM.  I am sure those with interest in the role of liability insurers will enjoy connecting with Geri at the meeting.

Excuse the length, but here is some additional musings on CME:

There are new ways to think about CME.  Traditional CME of sitting in lectures or online activities that try to implant knowledge in the brain suggest that physician can hold what is needed for their future patients in the brain, synthesize that knowledge and then ask the right questions every 20 minutes when each patients present with a diverse array of problems and symptoms in their offices or emergency rooms.  Most know this is impossible to do reliably.  We are currently living through a historical transition in medicine, making us the last profession to use computing to aide cognition.  Every other profession started using computing on a wide scale much earlier than medicine.  We are in the midst of this transition, so some don’t recognize how fundamental the shift is.  My residents use their smart phones and desktop computers to access knowledge all the time.  That is a huge change from when I went to medical school.  We were expected to recite differentials from our heads.  The next wave will include much more intelligent systems, and knowledge frameworks will begin to standardize the adhoc chaos that memory based care has wrought.  We are moving from a memory based educational paradigm, to an memory assisted and augmented paradigm.

 Larry Weed has written so eloquently about how the unaided mind cannot do what is needed.  Whether you agree with Larry’s premise and solution of Problem Knowledge Couplers or not, I recommend that anyone that is thinking about medical education and medical decision making should read his book Medicine in Denial and his recent paper in Diagnosis.  I know there are many on this listserv that watch their children work with computers and on their smartphones with amazement, and are not truly comfortable themselves with computers.  I have found that many experienced clinicians and clinical educators from my generation have a suspicion of computing, erroneously believing that poorly designed electronic health records represents medical computing. They see the problem with electronic records and believe that it is a bleak future.  A future of doctors staring at screens and not talking to the patient.   They believe computing in itself  is actually driving this wedge between the patient and physician, and that if we could just return to the good old days and just teach students in some ideal way, “cognitively debias them”, teach them about decision-making,  and then the problem of diagnostic errors is solved..presto! done.    We are late to the game, but the good news is that medicine will change.  It’s second nature to our students and residents and they will advance change and we will advance systems that assist us and the patients directly.

Best Art

Art Papier, MD
Chief Executive Officer
585.272.2630 | apapier at logicalimages.com<mailto:apapier at logicalimages.com>
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Associate Professor
University of Rochester College of Medicine

From: Michael Grossman [mailto:Michael.Grossman at MIHS.ORG]
Sent: Thursday, August 14, 2014 5:31 PM
Subject: Re: [IMPROVEDX] Diagnostic Error as Major Issue in Healthcare reported in ECRI and ASHRM Today

Actually insurance companies are at increased risk to lose money if diagnostic errors are not addressed. Many of the insurance companies actually present CME courses based on their actuarial experience and present data on causation of common mal practice claims. The MICA in Arizona also gives a discounted rate to those practitioners who attend these meetings.
I am not aware of any presentations regarding errors in medical diagnosis
Michael Grossman , MD MACP

From: Vic Nicholls [mailto:nichollsvi2 at GMAIL.COM]
Sent: Thursday, August 14, 2014 2:19 PM
Subject: Re: [IMPROVEDX] Diagnostic Error as Major Issue in Healthcare reported in ECRI and ASHRM Today


Follow the money.

On 8/14/2014 12:21 PM, Rob Bell wrote:
I have never completely understood why the insurance industry has not led the patient safety movement. Anyone know?

Rob Bell

Sent from my iPhone

On Aug 14, 2014, at 8:27 AM, Jason Maude <Jason.Maude at ISABELHEALTHCARE.COM<mailto:Jason.Maude at ISABELHEALTHCARE.COM>> wrote:

Many thanks for this.

To add to the risk/malpractice view, MMIC (the largest policyholder-owned medical liability insurance company in the Midwest) has dedicated the latest issue of its Brink Risk Solutions magazine (Summer 2014) to diagnosis. You can download it from this link http://www.mmicgroup.com/pdf/MMIC_BrinkMagazine_2014%20Summer.pdf


Jason Maude
Founder and CEO Isabel Healthcare
Tel: +44 1428 644886
Tel: +1 703 879 1890

From: Ruth Ryan <rryan at LAMMICO.COM<mailto:rryan at LAMMICO.COM>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Ruth Ryan <rryan at LAMMICO.COM<mailto:rryan at LAMMICO.COM>>
Date: Wednesday, 13 August 2014 20:03
Subject: [IMPROVEDX] Diagnostic Error as Major Issue in Healthcare reported in ECRI and ASHRM Today

Sadly, hospitals and hospital risk managers have been mostly absent from discussion or action on diagnostic error in medicine.
There are signs this may be changing.
Today ECRI published a short article titled,“The Difficulties in Defining and Preventing Diagnostic Errors”.
Subscribers may link to ECRI Institute Healthcare Risk Alerts at www.ecri.org<http://www.ecri.org>

The ECRI article references another article in the July issue of Journal of Healthcare Risk Management, a publication of ASHRM, the Association of Healthcare Risk Managers, which came into being with the assistance of the American Hospital Association.
The Journal of Healthcare Risk Mgt article is titled “Diagnostic error: Untapped potential for improving patient safety?” The abstract may be viewed at http://onlinelibrary.wiley.com/enhanced/doi/10.1002/jhrm.21149/

Senior Risk Management Education Specialist
1 Galleria Blvd., Suite 700
Metairie, LA 70001
E-Mail rryan at lammico.com<mailto:rryan at lammico.com>
Telephone (504) 841-2736
Fax (504) 841-5312



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