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

Peggy Zuckerman peggyzuckerman at GMAIL.COM
Fri Aug 22 18:55:08 UTC 2014


Some of the issue with "outliers" approach is that there may be great
difficulty in determining who really an outlier.  It may be less the issue
of the outlier, and more the "Not commonly found in..." patient.  Too often
women are not worked up for heart disease and very young women not checked
for breast cancer.  An over reliance of the statistics may be part of this,
with the statistics too often based on older or unsubstantiated data.

As we are increasingly able to gather larger data sets and use that info to
clarify patient groups, and to redefine diseases groups, then diagnosis
will improve.  Being more skeptical of the existing stats and the expected
profile of the disease and/or patient is still very necessary.

Peggy Z--statistically unlikely to have gotten metastatic kidney cancer,
and especially statistically unlikely to have a complete response to a
therapy statistically unlikely to be offered to anyone...


On Fri, Aug 22, 2014 at 8:10 AM, Robert Bell <rmsbell at esedona.net> wrote:

> Would studying the outliers of a "standard" presentation be of any value?
> What makes them outliers? Is there such a thing as pain receptor density
> differences from patient to patient for example?  And would that be DNA
> encoded?
>
> Rob Bell
>
> Sent from my iPad
>
> On 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>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>BJAIN at PARTNERS.ORG]
> Sent: Thursday, August 21, 2014 7:49 AM
> To: <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> 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>rryan at LAMMICO.COM]
> Sent: Tuesday, August 19, 2014 10:01 AM
> To: <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> 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>rryan at lammico.com
> Telephone (504) 841-2736
> Fax (504) 841-5312
>
>
> -----Original Message-----
> From: Jeffery Anderson [mailto: <janderson at BPCC.EDU>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
> To unsubscribe from the IMPROVEDX:
> mail to: <IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>
> IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
> or click the following link: <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>
> Address messages to: <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>
> For additional information and subscription commands, visit:
> <http://www.lsoft.com/resources/faq.asp#4A>
> http://www.lsoft.com/resources/faq.asp#4A
>
> <http://list.improvediagnosis.org/>http://LIST.IMPROVEDIAGNOSIS.ORG/
> (with your password)
>
> Visit the searchable archives or adjust your subscription at:
> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX>
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
>
> Moderator: Lorri Zipperer <Lorri at ZPM1.com>Lorri at ZPM1.com, Communication
> co-chair, Society for Improving Diagnosis in Medicine
>
> To unsubscribe from the IMPROVEDX list, click the following link:<br> <a
> href="
> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVE>
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVE
> DX&A=1"
> target="_blank">
> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBE>
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBE
> D1=IMPROVEDX&A=1</a>
> </p>
>
> Confidentiality Notice: The information contained in this e-mail (and/or
> the documents accompanying it) is private and confidential information
> belonging to the sender.  The information is intended only for the use of
> the
> individual(s) identified above and others who have been specifically
> authorized to receive it. If you are not the intended recipient or believe
> that you have received this communication in error, do not print, copy,
> retransmit, disseminate, or otherwise use the information. If you have
> received the transmission in error, please alert the sender that you have
> received this email by reply e-mail and delete the copy you received. Thank
> you.
>
> To unsubscribe from the IMPROVEDX:
> mail to: <IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>
> IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
> or click the following link: <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>
> Address messages to: <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>
> For additional information and subscription commands, visit:
> <http://www.lsoft.com/resources/faq.asp#4A>
> http://www.lsoft.com/resources/faq.asp#4A
>
> <http://list.improvediagnosis.org/>http://LIST.IMPROVEDIAGNOSIS.ORG/
> (with your password)
>
> Visit the searchable archives or adjust your subscription at:
> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX>
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
>
> Moderator: Lorri Zipperer <Lorri at ZPM1.com>Lorri at ZPM1.com, Communication
> co-chair, Society for Improving Diagnosis in Medicine
>
> To unsubscribe from the IMPROVEDX list, click the following link:<br> <a
> href="
> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVE>
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVE
> DX&A=1"
> target="_blank">
> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBE>
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBE
> D1=IMPROVEDX&A=1</a>
> </p>
>
>
> The information in this e-mail is intended only for the person to whom it
> is addressed. If you believe this e-mail was sent to you in error and the
> e-mail contains patient information, please contact the Partners Compliance
> HelpLine at <http://www.partners.org/complianceline>
> http://www.partners.org/complianceline . If the e-mail was sent to you in
> error but does not contain patient information, please contact the sender
> and properly dispose of the e-mail.
>
> To unsubscribe from the IMPROVEDX:
> mail to: <IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>
> IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
> or click the following link: <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>
> Address messages to: <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>
> For additional information and subscription commands, visit:
> <http://www.lsoft.com/resources/faq.asp#4A>
> http://www.lsoft.com/resources/faq.asp#4A
>
> <http://list.improvediagnosis.org/>http://LIST.IMPROVEDIAGNOSIS.ORG/
> (with your password)
>
> Visit the searchable archives or adjust your subscription at:
> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX>
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
>
> Moderator: Lorri Zipperer <Lorri at ZPM1.com>Lorri at ZPM1.com, Communication
> co-chair, Society for Improving Diagnosis in Medicine
>
> To unsubscribe from the IMPROVEDX list, click the following link:<br> <a
> href="
> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVE>
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVE
> DX&A=1"
> target="_blank">
> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBE>
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBE
> D1=IMPROVEDX&A=1</a>
> </p>
>
> To unsubscribe from the IMPROVEDX:
> mail to: <IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>
> IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
> or click the following link: <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>
> Address messages to: <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>
> For additional information and subscription commands, visit:
> <http://www.lsoft.com/resources/faq.asp#4A>
> http://www.lsoft.com/resources/faq.asp#4A
>
> <http://list.improvediagnosis.org/>http://LIST.IMPROVEDIAGNOSIS.ORG/
> (with your password)
>
> Visit the searchable archives or adjust your subscription at:
> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX>
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
>
> Moderator: Lorri Zipperer <Lorri at ZPM1.com>Lorri at ZPM1.com, Communication
> co-chair, Society for Improving Diagnosis in Medicine
>
> To unsubscribe from the IMPROVEDX list, click the following link:<br>
> <a href="
> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1>
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1"
> target="_blank">
> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1>
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
> </a>
> </p>
>
>
>
> ------------------------------
>
> Address messages to: <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>
> To unsubscribe from IMPROVEDX: click the following link:
>
> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1>
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
>
> or send email to: <IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>
> IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>
> Visit the searchable archives or adjust your subscription at:
> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX>
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
>
>
> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society
> for Improving Diagnosis in Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>
>
> ------------------------------
>
>
> To unsubscribe from IMPROVEDX: click the following link:
>
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>
> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society
> for Improving Diagnosis in Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>



-- 
Peggy Zuckerman
www.peggyRCC.wordpress.com







To unsubscribe from the IMPROVEDX list, click the following link:<br>
<a href="http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1" target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1</a>
</p>

HTML Version:
URL: <../attachments/20140822/fc1c0665/attachment.html>


More information about the Test mailing list