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

Peggy Zuckerman peggyzuckerman at GMAIL.COM
Fri Aug 22 17:12:45 UTC 2014


May I suggest that there be also an alternate approach, i.e., that the
failure to present with "classical" symptoms not thereby preclude a
diagnosis of that disease.  The must be a way to circle back to the point
at which one ruled out a diagnosis on that basis and once more give
consideration to the disease previously discounted.

As a kidney cancer patient, I am painfully aware of delayed diagnosis
because so few of us had the "classical triad" of blood in urine, flank
pain and a palpable mass in the belly.  That approach might have been
effective in finding tumors when no imaging was available, but also is
nearly predictive of an advanced tumor. No wonder the stats are so grim.

Peggy Zuckerman


On Fri, Aug 22, 2014 at 7:15 AM, BRIAN GOLDMAN <drhbg at rogers.com> wrote:

> 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> 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]
> 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]
> Sent: Thursday, August 21, 2014 7:49 AM
> To: 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]
> Sent: Tuesday, August 19, 2014 10:01 AM
> To: 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
> Telephone (504) 841-2736
> Fax (504) 841-5312
>
>
> -----Original Message-----
> From: Jeffery Anderson [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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-- 
Peggy Zuckerman
www.peggyRCC.wordpress.com







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