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

Vic Nicholls nichollsvi2 at GMAIL.COM
Fri Aug 22 22:30:47 UTC 2014


Dr. Goldman,

Your last sentance said everything. That's what happened in my case. If 
you added blaming the patient, calling them mental, that would cover 
everything I think.

I do believe that all the time spent in hospitals is detrimental to 
teaching doctors. The vast majority of doctors need time in offices, 
rather than ER's and hospitals. I would be interested to see the intern 
year be spent in outpatient PCP type practices. There is where you get a 
good idea of learning how to diagnose. That is basic to all docs.

Certain specialties could go elsewhere - surgery, ob/gyn etc.

Victoria

On 8/22/2014 3:34 PM, BRIAN GOLDMAN wrote:
> Pat,
>
> I see where you're heading.  All practitioners learnsome of these 
> cognitive pitfalls - either from making errors themselves or being 
> taught by a mentor who teaches the mentee to avoid the mistakes the 
> mentor has seen or heard about. What you are trying to do is 
> systematize the learnings.
>
> One cognitive bias that is in need of debiasing is the persistent 
> belief held by clinicians that a patient or a labor is normal or 
> uneventful in the face of growing evidence (and patient anxiety) that 
> the something is catastrophically wrong.
>
> 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 3:13:53 PM, Pat Croskerry 
> <croskerry at eastlink.ca> wrote:
>
>
> 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 <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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