Ten Commandments to Reduce Diagnostic Errors

Peggy Zuckerman peggyzuckerman at GMAIL.COM
Wed Aug 27 20:43:10 UTC 2014


Would there be value in teaching patients to ask, "What is the
chance/probability that this is the correct diagnosis?" or perhaps earlier
in the conversation (assuming there is a conversation), "What is the
probability of this symptom or test measure happening?".

Would being pressed to make such an evaluation be useful in keeping the
diagnosis being made too quickly?

Peggy Zuckerman


On Wed, Aug 27, 2014 at 6:54 AM, Jain, Bimal P.,M.D. <BJAIN at partners.org>
wrote:

>  1.       T o improve diagnosis, it is important to understand, I
> believe, how it is performed in actual practice.
>
> 2.       The real life method of diagnosis overcomes two major challenges
>
> (a)    The varying typicality of presentation of a given disease in
> different patients
>
> (b)   The need to determine a disease correctly in every individual
> patient with symptoms.
>
> 3.       The notion of typicality is equivalent to that of pretest
> probability as both indicate the frequency of a disease in patients with a
> given presentation. Thus a highly typical presentation as well as high
> pretest probability of a disease indicates most patients with a given
> presentation having a disease.
>
> 4.       A given patient with a certain presentation can thus be looked
> upon as being drawn from a series of patients with similar presentations.
>
> 5.       The typicality of a presentation is therefore not evidence for
> or against a disease in a given patient as it refers only to a frequency in
> a series and not to presence or absence of disease in the given patient.
>
> 6.       In actual practice therefore, a presentation is employed only as
> a clue, I suggest, from which we suspect a disease in a given patient. Thus
> highly characteristic chest pain in a 65 year old male with multiple
> cardiac risk factors as well as highly uncharacteristic chest pain in a
> healthy 40 year old woman with no cardiac risk factor make us only suspect
> acute myocardial infarction (acute MI)in both these patients.
>
> 7.       The suspected disease is then assumed or postulated to be
> present and thus given the status of a hypothesis.
>
> 8.       The hypothesis is then evaluated by a test and if a highly
> informative test result with likelihood ratio (LR) of 10 or higher is
> observed, the hypothesis is considered correct and the suspected disease
> diagnosed definitively.
>
> 9.       The hypothesis of acute MI in the above two patients is
> evaluated by performing an EKG. If acute Q wave and ST elevation changes
> (acute EKG changes) with LR of 13 are observed in both patients, acute MI
> is diagnosed with near certainty in both patients.
>
> 10.   A test result with LR of 10 or higher is usually obtained by
> performing a laboratory, imaging or biopsy study and occasionally from
> physical examination. For example, observation of unilateral erythematous,
> vesicular skin lesions would confirm diagnosis of herpes zoster suspected
> in a patient with unilateral back pain.
>
> 11.   Clinical diagnosis in actual practice is performed, I suggest in
> two sequential steps:
>
> (a)    A disease is suspected from a presentation
>
> (b)   It is diagnosed definitively from a test result with LR of 10 or
> higher.
>
>         12.During diagnosis therefore, the status of a disease is
>
>                 (a) That of a postulated disease or hypothesis in the
> first stage and
>
>                 (b) That of a confirmed or definitively diagnosed disease
> in the second stage.
>
>         13. In the CPCs published in NEJM, these two stages are clearly
> seen
>
>                (a) In the first stage, the discussing physician postulates
> a disease from given information (presentation) which has the status of a
> hypothesis
>
>                (b) In the second stage, the postulated disease is proven
> correct (or not) when the pathologist gives the result of a highly
> informative test result which is usually a biopsy ( or autopsy) finding but
>
>                       may be laboratory or imaging test result.
>
>         14. In general, it is rare to make a definitive diagnosis from a
> presentation alone. This may occur however when a highly informative test
> result is part of presentation.
>
>                For examp0le, herpes zoster is diagnosed definitively if a
> patient presents with painful, unilateral erythematous, vesicular skin
> lesions.
>
>         15. A presentation ceases to play any further role in diagnosis
> once a test result with LR of 10 or higher is observed. For example,
> pulmonary embolism is diagnosed definitively when a positive chest
>
>                CT angiogram (LR 21) is observed and deep vein
> thrombophlebitis is diagnosed definitively when a positive venous
> ultrasound study (LR 19) is found regardless of typicality of presentation.
>
>         16. It is seen from above account that probability does not seem
> to play any significant role in diagnosis in actual practice.
>
>         17. It is difficult to assess the value of the proposed Bayesian
> (probabilistic) to diagnosis in actual practice as there are hardly any
> published accounts of Bayesian diagnosis in actual patients. I present
>
>                below a patient discussed in a clinical problem solving
> exercise (Pauker, NEJM 1992) in which Bayesian diagnosis was attempted.
>
>         18. A healthy 40 year old woman without any cardiac risk factor
> presents with highly uncharacteristic chest pain and is found to have acute
> Q wave and ST elevation EKG changes.
>
>         19. The pretest probability of acute MI was estimated to be 7
> percent which was combined with known LR  of acute EKG changes of 13 by
> Bayes’ theorem to generate a post test probability of acute
>
>                MI of  50 percent. The Bayesian diagnosis from this post
> test probability obviously is that acute MI is indeterminate in this
> patient.
>
>         20. But the discussing physician ignored the Bayesian diagnosis
> and correctly diagnosed acute MI with near certainty from the strong
> evidence provided by acute EKG changes alone.
>
>         21. He diagnosed in this manner, I suggest, because acute EKG
> changes are known to diagnose acute MI correctly in 90 percent patients
> regardless of pretest probability (Rude Am J Card 1983)
>
>         22. I consider diagnosis to be a problem solving process which is
> similar to problem solving in any other field. It is strikingly similar for
> example as I discuss below, to the manner in which the great
>
>                American physicist Richard Feynman ‘diagnosed’ the cause of
> explosion of space capsule Challenger in 1986.
>
>         23. He carefully studied all available information about launch of
> Challenger, much as a physician discussing  a CPC would study available
> information about patient he is to discuss. From his study he
>
>                suspected malfunction of a rubber O ring which served as a
> valve due to extremely cold temperature (28 F) at time of launch. He
> postulated this explanation as a hypothesis which he evaluated
>
>                with his famous experiment conducted on television in which
> he dipped a replica of O ring in a glass of ice cold water. He found the O
> ring to become brittle and therefore incapable of functioning
>
>                properly as a valve thereby proving his hypothesis correct.
>
>          24. It will be noted Feynman did not employ probabilities,
> therefore his method is non-Bayesian. In fact, he had harsh words to say
> about what he felt was improper use of probabilities by NASA
>
>                 engineers. Feynman has narrated his investigation of
> Challenger incident in his inimitable style in his highly entertaining and
> instructive book  ‘What do you care whir other people think?’
>
>          25. It would be immensely useful to all of us  if the value (or
> not) of Bayesian approach in diagnosis is decisively established by a well
> conducted experimental study.
>
>          26. For if such a study shows a clear cut superiority over the
> usual approach which is about 85 percent accurate, we should all adopt it
> in our daily practice. If however, it is not found to be superior or
>
>                 Found to be inferior we should stop thinking about
> employing it and focus instead on learning more about how diagnosis is
> performed in actual practice.
>
>
>
>          Bimal
>
>
>
>
>
>         Bimal P Jain MD
>
>         Pulmonary-CriticalCare
>
>         NorthShore Medical Center
>
>         Lynn MA 01904
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
> *From:* Pauker, Stephen [mailto:SPauker at TUFTSMEDICALCENTER.ORG]
> *Sent:* Tuesday, August 26, 2014 1:12 PM
>
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Ten Commandments to Reduce Diagnostic Errors
>
>
>
> Well now, Dr Crab, one can craft similar prolems
>
> With every (any) commandment or rule.
>
>
>
>
>
> Rule 1: Every rule has exceptions. (Yes, but)
>
> Rule 2: Uncertainty and variation are not going away. (So manage them)
>
> Rule 3: Although History was important, it pales at the autopsy (or is it
> the MRI)
>
> Rule 4: Since history is a kind of test, testing only if it will change
> plans,
>
>              Is not an enforceable rule.
>
> Rule 5: Publication is merely telling a convincing story to reviewers.
> (What  makes evidence?)
>
> Rule 6: In a pinch, a brain outsmarts an iPad.
>
> Rule 7: Be wary of Intuition and “Evidence.”
>
> Rule 8: Although the uncommon can be important, Prevalence and Bayes Rule
> triumphs.
>
> Rule 9: Don’t ignore System I thinking (gut feelings)
>
> Rule 10: It’s only a guideline.”
>
>
>
> Steve ;-)
>
>
>
> *From:* Harold Lehmann [mailto:lehmann at JHMI.EDU <lehmann at JHMI.EDU>]
> *Sent:* Tuesday, August 26, 2014 9:30 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Ten Commandments to Reduce Diagnostic Errors
>
>
>
> Am I a crab to point out that “First Do No Harm” is false? Because we harm
> all the time—because we (and hopefully the patient) think it’s worth it.
> (Asking embarrassing History questions (#)…asking for disrobing…cold
> stethoscope…rectal exam…gagging pharyngeal exam…blood test…IV…VCUG…bone
> marrow aspiration…Need I go on?)
>
>
>
> So: “First, Do the Least Necessary Harm”?
>
>
>
> Also—re "think of serious and treatable conditions and act on them
> without delay”—does that reward availability bias? Or are we saying that
> any such “thought” means the likelihood is > 1/1,000, which I have found
> (in 20 years of eliciting from residents) is the threshold for referring
> infants to the ED for an LP, and therefore above threshold?
>
>
>
> Or should we say: “"think of serious and treatable conditions and act on
> them without delay, if the likelihood is high enough”
>
>
>
> Harold
>
>
>
> *From: *"<Patrice F. Hirning>", <MD>, <MACP>, CPHRM <phirning at UMIA.COM>
> *Reply-To: *Society to Improve Diagnosis in Medicine <
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, "Patrice F. Hirning, MD, MACP,
> CPHRM" <phirning at UMIA.COM>
> *Date: *Monday, August 25, 2014 at 8:52 PM
> *To: *"IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> *Subject: *Re: [IMPROVEDX] Ten Commandments to Reduce Diagnostic Errors
>
>
>
> What a great list. This should be shared with all medical students, house
> staff and practicing physicians. I plan to add these to my presentation to
> physicians about diagnostic error.
>
>
>
> Patrice
>
>
>
> *Patrice F. Hirning, MD, MACP, CPHRM*
> Medical Director
> UMIA Insurance, Inc.
> 310 East 4500 South, Suite 550
> Salt Lake City, Utah 84107
> Office 801.554.1145
> Fax 801.531.0381
> Toll Free 800.748.4380
> phirning at umia.com
>
>
>
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>
> *From:* Lorri Zipperer [mailto:Lorri at ZPM1.COM <Lorri at ZPM1.COM>]
> *Sent:* Sunday, August 24, 2014 7:13 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* [IMPROVEDX] Ten Commandments to Reduce Diagnostic Errors
>
>
>
> Forwarded by the moderator:
>
>
>
> From Dr. Leonardo Leonidas, Bangor, Maine 20 May 2001  Copyright 2001
>
> Given to his Son Len and Class 2001 Tufts University School of Medicine
>
>
>
>    1. Thou shalt First "Do No Harm."
>
>    2. Thou shalt think of serious and treatable conditions and act on them
> without delay.
>
>    3. Thou shalt remember that Diagnosis is History, History, History.
> Then confirm with clinical examination and more History.
>
>    4. Thou shalt request a test only if it will change your plan or help
> in predicting the outcome.
>
>    5. Thou shalt question "authority" such as your senior residents,
> attendings, experts, or even National guidelines.
>
>    6.  Thou shalt continue the debate and questioning even though the data
> is "IN."
>
>    7. Thou shalt maintain a high index of suspicion for uncommon
> presentations of the common.
>
>    8. Thou shalt recognize your own beliefs, biases, prejudices, and
> thinking style.
>
>    9. Thou shalt be wary of your hunches and intuitions. It is better to
> use Evidence Based Medicine.
>
>   10.  Thou shalt have an iPad* or a smartphone in your palm.
>
>
>
> *Palm Pilot in the first edition.
>
>
>
> Leonardo L. Leonidas, MD
>
> Assistant Clinical Professor in Pediatrics (retired 2008)
>
> Tufts University School of Medicine, Boston, USA
>
> nonieleonidas68 at gmail.com <mailto:nonieleonidas68 at gmail.com
> <nonieleonidas68 at gmail.com>>
>
>
>
>
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-- 
Peggy Zuckerman
www.peggyRCC.wordpress.com








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