TV Interview with Mark Graber and Sonia Millsom of Best Doctors - second opinion and information cascade

Hamm, Robert M. (HSC) Robert-Hamm at OUHSC.EDU
Mon Dec 8 15:50:22 UTC 2014


Victoria’s suggestion is to give the raw information (patient report) rather than the processed information (previous doctor assessment, diagnosis) to the second opinion doctor. This is a way to guarantee that the second opinion is “independent” of the first, and indeed this dependence is a powerful process.

1. Examples in the medical literature:
   Hatala, Norman and Brooks (1999) http://onlinelibrary.wiley.com/doi/10.1111/j.1525-1497.1999.tb00008.x/abstract  compared showing a radiology image with, and without, the referring doctor’s guess what it is. Makes a big difference. Radiologists dismiss that this is a problem, saying that the focus and the context is essential for their interpretation.
   Ramsey and colleagues (including me, https://smdm.confex.com/smdm/2012az/webprogram/Paper7002.html) looked at physicians who looked at (sleep) patient clinical data before and after a consult (diagnostic procedure, overnight sleep study).  The judgments after receipt of the consult were very strongly dependent on the consult (more than its accuracy warrants), and ignored the clinical data though it was still relevant.
   This has been called the “expertise heuristic”, http://persuasionpsych.blogspot.com/2012/06/expertise-heuristic.html, i.e., go with what the expert says rather than doing the laborious process of considering the evidence yourself.
  We need to recognize that the patient also is a conduit of the earlier doctor’s conclusion. Even if the patient does not show the first doctor diagnosis to the second opinion doctor, the patient’s understanding and telling of own evidence may be shaped by it.

2. Information cascade.
  The process of a series of experts, reviewing a case taking their own observations and also considering the summary observation(s) of previous experts, is formally analyzed as “information cascade”. http://en.wikipedia.org/wiki/Information_cascade, starting with Bikhchandani, S., Hirshleifer, D., and Welch, I. (1992), "A Theory of Fads, Fashion, Custom, and Cultural Change as Informational Cascades," Journal of Political Economy, Volume 100, Issue 5, pp. pp. 992-1026<http://www.irvinehousingblog.com/wp-content/uploads/2008/03/atheoryoffads.pdf>.
  Its applicability to medicine has been sugested before http://sites.uci.edu/dhirshle/files/2011/02/information-cascades-and-observational-learning.pdf, in a short paragraph on page 11, but the focus is on physicians’ influencing each others’ practice (herd effects, producing local variations) rather than on the second opinions for an individual patient.
  Another example is the neglect of medical symptoms reported by patients with psychiatric diagnosis, based on the simplified assumption that they are making it up. [This was the topic of a 2013 post on this IMPROVEDX list, from a resident.]
   The economic analysis presumes rationality on the part of each judge in the chain. Given that each, and the previous, is provided with information that is not 100% accurate, what is the rational diagnosis for each to issue? This might serve as a standard against which to compare the actual performance of second opinion issuers.

3. Is independence of second opinion the answer? It would not guarantee perfect accuracy; it would go against some cognitive shortcuts that probably should not be taken. It would cost in terms of physician effort. Given that physicians are reimbursed on a “per visit” basis rather than a “per thoughtful analysis” basis, it would not cost patients or insurance companies more, as long as diagnostic tests were not unnecessarily repeated.


From: Vic Nicholls [mailto:nichollsvi2 at GMAIL.COM]
Sent: Sunday, December 07, 2014 6:22 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] TV Interview with Mark Graber and Sonia Millsom of Best Doctors

Mark,

What about not giving the notes/thoughts of the first physician to the second? This is where I found I was the most successful. The problems I had in terms of missed/delayed diagnosis where when the first physician gave his thoughts to the second. When I stopped the transfering of records, it seemed to work every time.

That was with one particular specialist. That is the only other item I've noticed. I suspect it was because of a personality issue rather than anything else.

Victoria
On 12/7/2014 11:11 AM, Mark Graber wrote:

Sonia Millsom (Best Doctors) and I were guests this week on the “Larry Parks Show”, a NYC TV production, to talk about diagnostic errors and second opinion program offered by Best  Doctors.

The link to the 30 minute interview is here<https://urldefense.proofpoint.com/v2/url?u=https-3A__vimeo.com_113742396&d=AAMDaQ&c=qRnFByZajCb3ogDwk-HidsbrxD-31vTsTBEIa6TCCEk&r=xRJEBCjBmL1ypS8G4qfsiN0ww2Uty8FEqU-Ye79RFyM&m=_LH9hGpTHsAZzRwrON3hIN1C4p_fITus0IKxcCSoYs8&s=5TckilG5LnwClzZaMD0iC3LT1fCRtWyzaJkQTa2NfIA&e=>:           (https://vimeo.com/113742396<https://urldefense.proofpoint.com/v2/url?u=https-3A__vimeo.com_113742396&d=AAMDaQ&c=qRnFByZajCb3ogDwk-HidsbrxD-31vTsTBEIa6TCCEk&r=xRJEBCjBmL1ypS8G4qfsiN0ww2Uty8FEqU-Ye79RFyM&m=_LH9hGpTHsAZzRwrON3hIN1C4p_fITus0IKxcCSoYs8&s=5TckilG5LnwClzZaMD0iC3LT1fCRtWyzaJkQTa2NfIA&e=>)

Larry’s main interests are in the area of economics, so we briefly discussed the current federal funding for dx error research.  We’re not exactly sure of the amount, but its probably less than $2M/year right now.  This is for a problem that accounts for an estimated 40,000 - 80,000 deaths per year in the US.  By way of comparison, breast cancer accounts for 40,000 deaths per year, and receives NIH research funding of $660,000,000.

Best Doctors is a Founding Member of SIDM, and shares our vision to improve the reliability of diagnosis.  Best Doctors provides second opinions for patients, an extremely valuable service IMHO.  Fresh eyes on a case add perspective and can help catch mistakes.  I’d like to see more second opinions in medical practice.  How can we encourage these?  How can we identify the clinicians  most interested and most skilled in providing second opinions?  Seems like an admirable career path to me — so we could add to specialists and intensivists and hospitalists - “Second Opinionist”


Mark L Graber MD FACP
President, SIDM





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