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

Pat Croskerry croskerry at EASTLINK.CA
Fri Aug 22 19:12:52 UTC 2014


Brian: the history of cognitive de-biasing has been one of gloom and doom,
but I believe the pessimism has been ill founded, and in any event Medicine
cannot afford not to address it. There is an imperative.

We can certainly teach about the properties of the cognitive biases that
lead to stereotypical errors that have a high impact.

 

Clinical precedents have led to the cultivation of a number of debiasing
strategies in Medicine over the years (establishing a differential
diagnosis, rule out worst case scenarios, classic pitfalls to avoid in all
disciplines, red flags, other forcing functions etc),

but we can now get more specific and start teaching what biases to expect in
certain clinical situations, as well as specific strategies (mindware) to
avoid them. This looks like the next major frontier in the management of
diagnostic failure.

Pat Croskerry

 

From: BRIAN GOLDMAN [mailto:drhbg at ROGERS.COM] 
Sent: Friday, August 22, 2014 11:16 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> 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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