Commonest error in medicine

Robert Bell rmsbell200 at YAHOO.COM
Sun Dec 7 03:44:32 UTC 2014

Peggy and Charlie,
Could something like that be developed here on line and then tried out somewhere?
      From: Charlie Garland - The Innovation Outlet <cgarland at INNOVATIONOUTLET.BIZ>
 Sent: Saturday, December 6, 2014 5:17 PM
 Subject: Re: [IMPROVEDX] Commonest error in medicine
Peggy - Thank you for sharing the Patient's Toolkit.  I hadn't seen this before, but it seems like an outstandingly good idea, as an attempt to elicit as much participation by (information from) the patient as early as possible.  I have a few comments upon reflection:   
   - This form would lend itself well to being turned into a mobile app (either native or a mobile-web application).  Doing so could make it much more interactive, and give availability of much richer access to supplemental information (e.g. connecting to online resources such as WebMD), and allow it to have contingent/contextual information available (e.g. if headache is indicated, automatically ask what type of pain relievers the patient has taken, over what time period, with what effects, etc.).
   - The questions posed are a good start, but I believe do not go nearly far enough.  The explicit mention of asking "What else could this be?" is a fantastic concept -- it essentially prompts the patient with a stimulus for critical thinking (i.e. challenging the assumption or initial diagnosis).  But there is a comprehensive set of other "...else" question types that ought to also always be considered -- just a few examples might be:
   - Where-else questions: "where else have you traveled recently (e.g. where you might have been exposed to unusual germs, chemicals, insects, foods, etc.)?" ... "where else do you feel any sort of symptoms, pressure, tightness, itch, weakness, etc.?"
   - Who-else questions: "who else in your family has ever had certain symptoms, or illness, or prone to injury, etc.?" ... "who else have you been in close contact with, have had any sexual contact with, have noticed behaving/responding differently?"
   - When-else questions: "when else have you experienced these symptoms -- at any time in the past, even many years ago?" ... "when else does the pain/symptom feel more significant (i.e. when you bend, first wake up, after a meal, while exerting energy, at work, when lying down, etc.)?"
   - How-else questions: "how else might this have happened -- have you changed anything at all about your lifestyle, taking any new vitamins, under pressure at work, sleeping differently, playing sports, lifting/moving/cleaning, etc.?" ... "how else have any conditions in your environment or activity level changed?"
   - Why-else questions: "why else are you taking the (meds, vitamins, etc.) that you have had?" ... "why else have you been experiencing stress in your life?" [see myriad Motivational Interviewing examples]
   - What-else questions: "what else can you do to avoid the situations that worsen your symptoms?" ... "what else do you have available to you to improve your overall health?"
   - You may recognize the above set as the "six universal questions," which is merely a start, but a good one for continuously prompting the patient (and clinician) to ask probing, explorative questions...that might bring out additional, valuable information.  This process ("Explorative Inquiry") comes from the logical model called "Cubie" that some people use in brainstorming, design, planning, analysis, etc. (see:
   - There are obviously a very wide range of such questions that should be added to the above list, and (again) some that would be much more important to ask, given certain conditions or initial information (e.g. if pain in the chest is indicated, a specific set of inquiries would be appropriately initiated)
   - I do envision some concern on relying upon any such tool too much to elicit information.  Doing so has the risk of introducing a bias (e.g. focusing on what the patient has been able to recall on his/her own, absent of probing).
   - Related to the above, it would be important for any clinician to explore more deeply within, and beyond, whatever information a patient may offer up initially.  All clinicians should remain mindful that patients do not always provide true, thorough, or accurate information (there are many reasons for this, which I won't get into here)!
Just a few thoughts.  I believe there are many different ways of getting a patient more involved, and at an earlier juncture, than is the norm.  Anything that promotes such deeper, earlier engagement is a good thing, in my opinion.
Thank you for sharing...================================================= Charlie Garland, President
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-------- Original Message --------
Subject: Re: [IMPROVEDX] Commonest error in medicine
From: Peggy Zuckerman <peggyzuckerman at GMAIL.COM>
Date: Sat, December 06, 2014 3:27 pm

 Dear Robert and All,
This discussion is so critical to patients, who are always at the losing end of the late, missed or erroneous diagnosis. They SHOULD be more involved in this process, and learn that diagnosing is not a product but a process. There will be dynamics and uncertainty in play for all which patients rarely understand. This discussion reflects that!

However , I had hoped that I would see a list emerge which could guide patients as they participate in this process, along the lines of the Patient ToolKit offered on the site.  That is to prep the patient, and implicitly recognizes their responsibility to get their story to the doctor.

I think of the early public service ads about "ten signs of cancer" or "early warning re diabetes" or similar, and think that such a list can be developed for patients. Getting referred by the GP to the right specialist is no guarantee, and may limit the type of review given the patient.  Would an oncologist react differently to a very low, unexplained hemoglobin as the internist and so on.

Attaching the PDF of the Patient Toolkit, available freely for re-use, of course.
Peggy Z

On Sat, Dec 6, 2014 at 8:21 AM, Robert Bell <0000000296e45ec4-dmarc-request at> wrote:

Dear all,
 I had the idea that instead of talking and sharing thoughts on a list server that some of the good will, and the time of the contributors could be used to actually DO something useful. Be it a resolution sent to the organizers of the list on a particular issue, or the basis for an article/publication. This, and perhaps a little naively, considering that the most successful technology companies operate on the basis of creativity and inclusiveness being intertwined. And this list had an amazing cross section of talent and diversity. Somehow I had the idea that we could miraculously DO something to help with the apperent lack of progress in the last 15 years since the IOM report on Errors.
 But I think the hurdles of confidentiality, available tIme of contributors, differing society aims, competing projects, differing individual aims, patent considerations, litigation issues, and institute affiliations, etc., etc, are likely to make this all too great of an uphill battle.
 Thank you for all being so gracious, to at least try to move the idea forward.
 Robert Bell, M.D.
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Peggy Zuckerman
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