Diagnostic Error as a Major issue

robert bell rmsbell at ESEDONA.NET
Fri Aug 22 02:21:16 UTC 2014

I am not sure if this was posted.  So will send it off line to those involved in the discussion.

Rob Bell

Dear Bimal,


The variations in presentation are so important. Just think of sensory nerve ending density from patient to patient, anatomical variations, lean vs obese, where the stone is in the bile duct system, and diferences from men and women (e.g. myocardial pain), and there maybe even racial and ethnic differences that we know little about, etc., etc. 

This against the background of the insensitivity of our diagnostic tests, it is a wonder we do so well! 

And my pet peeve, the results from the use of a stethoscope in people with different levels of experience and hearing abilities. After all the years of using a stethoscope we have no idea how accurate it is in different sub-groups of HCP's. 

So we not only have to factor in the variations in presentation, but also the variations in the sub-groups of HCPs that are doing the diagnosis! 

Can women as a whole hear heart sounds better than men? Do we even know that?

In our research don't we need to know the basics in parallel with any computer or other help in diagnosis that we work upon?

Rob Bell, M.D., Ph.C.

Sent from my iPad

On Aug 21, 2014, at 3:49 AM, "Jain, Bimal P.,M.D." <BJAIN at PARTNERS.ORG> wrote:

> 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

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