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

Jain, Bimal P.,M.D. BJAIN at PARTNERS.ORG
Fri Aug 22 16:51:22 UTC 2014


Hi Brian, thank you for your interest. The whole idea is to look at presentations in patients with a certain disease to get an idea about the wide range. This could be done in 50 or 100 consecutive patients as long as the number is fairly large It could be done quite simply. For example, I tried to do it myself in 30 consecutive patients with pulmonary embolism at my medical center. I looked at the initial H&P on each patient in the computer and noted  down findings which led to a chest CTA being ordered. As expected there were many patients with malignancy or who were post op and developed dyspnea and/or chest pain. But there were a few patients for example, with persistent hypoxia in presence of pneumonia  or fatigue in presence of colon Ca , who had somewhat unusual presentations. I would like to do this survey myself but lack time as I am in practice. The data entry does not  need to be very elaborate. I found that once you start looking things sort of leap out at you. The idea is to get to appreciate the wide range of typicality of presentations in a given disease. I hope you find this helpful

All the best

Bimal

Bimal P Jain MD
Pulmonary-Critical Care
Nort6hShore Medical Center
Lynn MA 01904

From: BRIAN GOLDMAN [mailto:drhbg at ROGERS.COM]
Sent: Friday, August 22, 2014 10:16 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Diagnostic Error as Major Issue in Healthcare reported in ECRI and ASHRM Today

Dr. Jain,

The data entry challenge involved in extracting and recording the actual symptoms and signs of the more recent 100 cases of a particular diagnosis would be daunting.

I'm looking to simplify the process.  Are there stereotypic or archetypal misdiagnoses that could be incorporated into teaching in a formal way.  Could typical cognitive biases that lead to stereotypic high-impact errors be taught?

Brian

Brian Goldman, MD, MCFP(EM), FACEP
Mount Sinai Hospital, Room 206
600 University Avenue
Toronto, ON M5G 1X5
416-822-5044 phone
416-586-4719 fax

On Friday, August 22, 2014 9:59:53 AM, "Jain, Bimal P.,M.D." <BJAIN at PARTNERS.ORG<mailto:BJAIN at PARTNERS.ORG>> wrote:

Hi Pat, thank you for your comments. I have admired your work on diagnostic biases over the years. I have often wondered why we have these biases specially representativeness. Could it be that we are only taught about typical presentations of a disease which leads us to believe that it only occurs with typical presentations in all patients. I think if we are taught in terms of distribution of typicality of presentations instead, we may have less of this bias. I also think that displaying presentations of a given disease in a large number of actual patients on a computer file may help reduce this bias.

With warm regards,

Bimal

-----Original Message-----
From: Pat Croskerry [mailto:croskerry at eastlink.ca<mailto:croskerry at eastlink.ca>]
Sent: Thursday, August 21, 2014 5:31 PM
To: 'Society to Improve Diagnosis in Medicine'; Jain, Bimal P.,M.D.
Subject: RE: [IMPROVEDX] Diagnostic Error as Major Issue in Healthcare reported in ECRI and ASHRM Today

Bimal: good points.
Often in clinical medicine the issue seems to come down to separating the signal from the noise - great work on this topic was done by Swets and Tanner many years ago.
There is a continuum of 'manifestness' along which all diseases present. The highly manifest (pathognomonic) are at one end, and the least manifest
(woolly/indistinct) at the other. For the former the signal-noise curves are almost completely distinct from each other, whereas for the latter they may overlap completely. Research studies often focus on the manifest presentations which is a distortion of clinical experience. Diagnostic acumen seems to require an ability to effectively separate signal from noise with minimal effort.
The two main biases involved here are 'Representativeness' (looking for characteristics that conform to a typical member of the group, and 'Ascertainment bias' (seeing what you expect to see) which is not quite the same thing.
ROWS (rule out worst case scenario) is a strategy that emergency physicians often use to avoid the charge of neglecting the base rate.
Pat



-----Original Message-----
From: Jain, Bimal P.,M.D. [mailto:BJAIN at PARTNERS.ORG<mailto:BJAIN at PARTNERS.ORG>]
Sent: Thursday, August 21, 2014 7:49 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Diagnostic Error as Major Issue in Healthcare reported in ECRI and ASHRM Today

I did not have a chance to comment during John Ely's interesting webinar yesterday as I joined in by telephone. Here are my thoughts about his important study.
1. A major reason for failure to broaden differential diagnosis may be our lack of awareness of the wide variation in clinical presentations of a given disease ranging from highly typical to highly atypical in different patients. This may be due to medical school and textbook teaching which focuses primarily on typical presentations of a disease. Awareness of variation could be increased, I suggest, by looking at summaries of presentations in about one hundred consecutive patients with a given disease seen at a large medical institution. These summaries could be stored in a computer file which could be made available to all interested physicians.

2. An atypical presentation is often interpreted as low pretest evidence due to low pretest probability of a disease which may be ruled out without further testing. I believe, a presentation should be looked upon as a clue to a disease and not pretest evidence which should be ruled in or out by further testing. This would avoid premature closure.

3. The rule of not neglecting base rate is a statistical rule which may not apply in a given, individual patient as we saw in the patient found to have neurosyphilis. I believe it is all right to break this rule by suspecting a rare disease if all other suspected diseases are found not to be present.

4. There is so lttle we know about how diagnosis is performed in actual practice or should be performed to minimize diagnostic errors. I would like to thank John Ely and other investigators who have started to look at diagnosis in actual practice and increase our understanding of this important process.

All the best,

Bimal

Bimal P Jain MD
Pulmonary-Critical Care
NorthShore Medical Center
Lynn MA 01904

-----Original Message-----
From: Ruth Ryan [mailto:rryan at LAMMICO.COM<mailto:rryan at LAMMICO.COM>]
Sent: Tuesday, August 19, 2014 10:01 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Diagnostic Error as Major Issue in Healthcare reported in ECRI and ASHRM Today

Bravo and hats off to you, Jeffery!  If critical thinking skills can be built into the community college program training paramedics in Bossier Parish, North Louisiana, never let it be said such training is ethereal, too difficult, or relevant only to the ivory tower.

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


-----Original Message-----
From: Jeffery Anderson [mailto:janderson at BPCC.EDU<mailto:janderson at BPCC.EDU>]
Sent: Sunday, August 17, 2014 9:26 PM
Subject: Re: Diagnostic Error as Major Issue in Healthcare reported in ECRI and ASHRM Today

I am developing a module on critical thinking for my paramedic program.
Besides using Dr. Croskerry's articles and information from the Foundation for Critical Thinking, I am also using the textbook Patient Safety in Emergency Medicine by Croskerry and Emergency Medicine Decision Making by Weingart as references.  In addition I have been following the work of Dr.
Kevin deLaplante of the Critical Thinker Academy.

Jeffery D. Anderson, NREMT-P
Paramedic Program Director
Bossier Parish Community College
Office Phone (318) 678-6403
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