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

Vic Nicholls nichollsvi2 at GMAIL.COM
Tue Aug 19 10:43:13 UTC 2014

Dr. Bruno,

You do bring up a very good point.

What I've noticed is that there can be a dichotomy in terms of whether 
the subject is a drug or not. While reviewing the literature for items 
that pertain to my issues, none of them touted drugs, but were 
refinements on diagnoses, or studies that corroberated/earlier findings. 
Note that none of these studies dealt with large classes of drugs like 
statins and diabetic related issues.

I don't look at percentages as much as I do the #'s themselves. I guess 
I was brought up in the late 90's to look at research in a very 
different way. Much of what I got in a different subspecialty then what 
I review now, was from teaching doctors who at the time, were from one 
of the leading institutions in that field.


On 8/18/2014 10:36 AM, Bruno, Michael wrote:
> 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,
> *Description: Description: Description: 
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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
> 500 University Drive, Mail Code H-066
> Hershey, PA  17033
> Phone: (717) 531-8703
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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
> Pat,
> 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.
> Victoria
> 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.
>     Pat
>     *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>
>     ______________________________
>     cid:image001.png at 01CF6DCC.9CEF2CF0
>     www.visualdx.com <http://www.visualdx.com/>
>     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
>     Money.
>     Follow the money.
>     Victoria
>     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:
>             Ruth
>             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
>             Regards
>             Jason
>             Jason Maude
>             Founder and CEO Isabel Healthcare
>             Tel: +44 1428 644886
>             Tel: +1 703 879 1890
>             www.isabelhealthcare.com <http://www.isabelhealthcare.com/>
>             *From: *Ruth Ryan <rryan at LAMMICO.COM
>             <mailto:rryan at LAMMICO.COM>>
>             *Reply-To: *Society to Improve Diagnosis in Medicine
>             <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/
>             Ruth
>             Ruth Ryan RN, BSN, MSW, CPHRM
>             Senior Risk Management Education Specialist
>             LAMMICO
>             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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