Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

Robert Bell rmsbell200 at YAHOO.COM
Mon Jan 12 05:40:08 UTC 2015


The acqisition of the data I can see is an art, but why do we then destroy, alter, or sequester the accuracy of the final diagnostic coclusions wth such passion. Making available ALL data is where we should ALL be focussed. Nothing less is deceiving ourselves that we are doing something worthwhile.

Getting to that goal needs strategy, massive change in attitude, and a far greater emphasis on the patient and less on profit. 

Can a profit based system ever work with ACCURATE diagnostic reporting? Perhaps not. Perhaps with protections?

Rob Bell



Sent from my iPad

On Jan 11, 2015, at 5:59 PM, "Swerlick, Robert A" <rswerli at EMORY.EDU> wrote:

> A test to show whether you are correct?
> 
> Robert A. Swerlick, MD
> Alicia Leizman Stonecipher Chair of Dermatology
> Professor and Chairman, Department of Dermatology
> Emory University School of Medicine
> 404-727-3669
> From: Robert M Centor [rcentor at UAB.EDU]
> Sent: Sunday, January 11, 2015 4:47 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"
> 
> I must disagree.  The art is in the data collection.  Taking a history is much more complex than asking a list of questions.  Each question has many branch points depending upon how one interprets the words, the body language, and the patient’s context.
> 
> I do believe that this process requires artistry.  What am I missing?
> ==============
> 
> Robert M Centor, MD, MACP
> 
> Regional Dean, UAB Huntsville Regional Medical Campus
> 301 Governors Drive
> Huntsville, AL 35801
> 
> Office: 256-539-7757
> Fax: 256-551-4451
> 
> Chair, ACP Board of Regents
> 
> Professor, General Internal Medicine
> UAB
> FOT 720
> 1530 3rd Ave S
> Birmingham, AL 35294-3407
> 
> 
> From: Alan Morris <Alan.Morris at IMAIL.ORG>
> Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Alan Morris <Alan.Morris at IMAIL.ORG>
> Date: Sunday, January 11, 2015 at 10:44 AM
> To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"
> 
> Beo Centor makes the argument that medical diagnosis is “science” plus “art,” and cannot be more like engineering  Science and art are two broad terms that can have multiple meanings, the specific definitions of which determine subsequent argument.  The science of medicine at the patient-clinician encounter is flimsy.  Replicable methods are rarely pursued.  The art of medicine is sometimes uses as a wastebasket for the remarkable achievements of accomplished clinicians (e.g., William Osler) while ignoring his admonition that method is required for all but geniuses.
> 
> I believe Dr. Centor has confounded two constructs that are frequently not adequately identified and separated:
> System of interest:   Sick patients are more complex than mechanical or electrical systems.  A patient, for example, is much more complex than an airplane.  This leads many to conclude that engineering solutions, like those in airplanes, cannot be done in medicine.  However, the human decision-maker (and his/her cognitive limitations) is common to both systems.
> Human decision-maker cognitive limits (4±1 constructs in short-term memory before decisions become degraded):  The clinician decision-maker and the pilot decision-maker are both cognitively limited by the same amount – and they are both overloaded by information.  Pilots can enjoy the benefit of autopilot programs, because the engineers have invested the effort to understand the control needs of airplanes.  We can clearly do the same for clinician decision-makers – feasibility is well-established – but the medical community is so married to the “cottage industry” model of the independent clinician decision-maker that we have not invested the effort to establish and scale autopilots for clinicians.
> Healthcare challenges require a combination of autopilot and independent clinician decision-maker (cottage industry).  We seem to be making precious little progress with this combination.  I know of no systematic effort to pursue scaling of autopilot programs  in medicine.  This may, in part, be what led Eric Topol, MD to claim that medicine is so conservative, its thinking is ossified.
> 
> Alan
> Alan H. Morris, M.D.
> Professor of Medicine
> Adjunct Prof. of Medical Informatics
> University of Utah
> 
> Director of Research
> Pulmonary/Critical Care Division
> Sorenson Heart & Lung Center - 6th Floor
> Intermountain Medical Center
> 5121 South Cottonwood Street
> Murray, Utah  84157-7000, USA
> 
> Office Phone: 801-507-4603
> Mobile Phone: 801-718-1283
> 
> From: Robert M Centor <rcentor at UAB.EDU>
> Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Robert M Centor <rcentor at UAB.EDU>
> Date: Sunday, January 11, 2015 at 7:59 AM
> To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"
> 
> Bob Latino asks an important question.  To rephrase – why cannot medicine be more like engineering?
> 
> Patients experience the same disease in many different ways.  They relate different symptoms and have different physical findings and laboratory tests.  
> 
> The history gives us the greatest challenge.  Patients describe their symptoms in different ways.  Some patients deny their symptoms.  Some patients exaggerate their symptoms.  The great historian needs the art of reading between the lines.  We read body language.  We know when to seek additional information from family members or friends.
> 
> If we enter the proper data into our computer (either our biological computer or a program someone else has written) then we often (but not always) get to the correct diagnosis.
> 
> Additionally, while some patients follow Occam’s Razor, having a single cause for their symptoms, other follow Hickam’s Dictum (a patient can have as many diagnoses as he/she damn well please).  When patients have shortness of breath, we ask if the heart, lungs, muscles, etc are causing the symptoms.  Many patients have multiple diseases.  Are the new symptoms due to their known diseases or an additional new problem.
> 
> I therefore believe the diagnosis brilliance combines the science and the art.  The great diagnosticians spend much time using system 1 thinking and know when and how to proceed to system 2 thinking.  Knowing the textbook is not enough.  We need experience – thus the art.
> ==============
> 
> Robert M Centor, MD, MACP
> 
> Regional Dean, UAB Huntsville Regional Medical Campus
> 301 Governors Drive
> Huntsville, AL 35801
> 
> Office: 256-539-7757
> Fax: 256-551-4451
> 
> Chair, ACP Board of Regents
> 
> Professor, General Internal Medicine
> UAB
> FOT 720
> 1530 3rd Ave S
> Birmingham, AL 35294-3407
> 
> 
> From: Bob Latino <blatino at RELIABILITY.COM>
> Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Bob Latino <blatino at RELIABILITY.COM>
> Date: Friday, January 9, 2015 at 1:51 PM
> To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"
> 
> I ask this as a non-clinician, "Should healthcare be more art than science?"
>  
> Understanding there are many unknowns in the field of medicine, as there are in science; but with regards to the 'knowns', shouldn't it be more science than art?
>  
> I come from the engineering disciplines (so from the left brain world), but with the 'knowns' there is a lot more structure and less variability in the application of the physical sciences in engineering. 
>  
> With what is 'known' in medicine, why does there appear to be so much variability in 1) what is known (and who knows it) and 2) how it is effectively and consistently applied to the benefit of the patient.
>  
> Perhaps a naive question, but nonetheless on my mind as an layman observer:-)
>  
> Robert J. Latino, CEO
> Reliability Center, Inc.
> 1.800.457.0645
> blatino at reliability.com
> www.reliability.com
>  
> From: David Lawrance [mailto:david.lawrance at gmail.com] 
> Sent: Friday, January 09, 2015 2:37 PM
> To: Society to Improve Diagnosis in Medicine; Bob Latino
> Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"
>  
> And, thank goodness, most people seem willing to pay us, again.
>  
> At this point it is generally protocol to mention that healthcare is more art than science. I think that is another way of saying that artists are more accident-prone than are scientists.
>  
> David
>  
> On Wed, Jan 7, 2015 at 6:43 AM, Bob Latino <blatino at reliability.com> wrote:
> We never seem to have the time and budget to do things right, but we always seem to have the time and budget to do them again!
>  
> Robert J. Latino, CEO
> Reliability Center, Inc.
> 1.800.457.0645
> blatino at reliability.com
> www.reliability.com
>  
> From: Jason Maude [mailto:Jason.Maude at ISABELHEALTHCARE.COM] 
> Sent: Wednesday, January 07, 2015 4:39 AM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"
>  
> Thanks for alerting us to this article. One of the really positive things about the article is not just the improved care now being given but a great example of the Chief Medical Office and his senior colleagues managing/leading and setting a standard of care. He states in the article "I realize that many colleagues may see methods like ours as too intrusive on their clinical practice and may say that they don’t have the time.” I believe we need to see much more of this in hospitals. Too often, for example, we see DDS viewed as an end in itself rather than a tool to help with setting a standard of care and I think this explains why adoption of these tools is still relatively low.
>  
> Regards
> Jason
>  
> Jason Maude
> Founder and CEO Isabel Healthcare
> Tel: +44 1428 644886
> Tel: +1 703 879 1890
> www.isabelhealthcare.com
>  
> From: <Bruno>, Michael <mbruno at HMC.PSU.EDU>
> Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, "Bruno, Michael" <mbruno at HMC.PSU.EDU>
> Date: Tuesday, 6 January 2015 20:23
> To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> Subject: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"
>  
> Greetings IMPROVEDX List-serve colleagues, and Happy New Year! 
>  
> Thanks to Jason and Thomas for starting this years’ discussion.
>  
> The attached article appeared in the Sunday New York Times.   I thought it was relevant to our group’s discussion.
>  
> http://www.nytimes.com/2015/01/05/opinion/doctor-shut-up-and-listen.html?_r=0
>  
>  
> All the best,
>  
> <image001.png>
> Michael A. Bruno, M.D., F.A.C.R.
> Professor of Radiology & Medicine
> Director of Quality Services & Patient Safety
> The Milton S. Hershey Medical Center
> Penn State College of Medicine
> 500 University Drive, Mail Code H-066
> Hershey, PA  17033
> 
> Phone: (717) 531-8703
> Fax:      (717) 531-5596
> 
> e-mail: mbruno at hmc.psu.edu
>  
> <image002.png>
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>  
> From: Carroll, Thomas [mailto:Thomas_Carroll at URMC.ROCHESTER.EDU] 
> Sent: Tuesday, January 06, 2015 1:44 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] "Early diagnostic suggestions improve accuracy of GPs"
>  
> Interesting.  My question would be how this would translate to the real world.  In this artificial environment we know whether or not the “correct” dx is in the list of suggested dx’s.  That would not be the case in the real world.
>  
> Thomas M. Carroll M.D., Ph.D.
> Assistant Professor, General Medicine & Palliative Care
> University of Rochester
> thomas_carroll at urmc.rochester.edu
> Pager 5-1616 #3872
> Tel: 585-275-7424 (General Medicine Office)
> Tel: 585-273-1154 (Palliative Care Office)
> Tel: 585-341-6775 (Resident Practice, Highland Hospital)
>  
> From: Jason Maude [mailto:Jason.Maude at ISABELHEALTHCARE.COM] 
> Sent: Tuesday, January 06, 2015 1:25 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: [IMPROVEDX] "Early diagnostic suggestions improve accuracy of GPs"
>  
> This is very interesting study just published in the British Journal of General Practice which also highlights the potential value of patients using symptom checkers and handing the results to their doctor at the start of the consultation. This would get over the current technical challenges of a system automatically producing a differential from more complex cases with multiple symptoms.
>  
> http://bjgp.org/content/65/630/e49
>  
> Regards and Happy New Year to the group.
> Jason
>  
> Jason Maude
> Founder and CEO Isabel Healthcare
> Tel: +44 1428 644886
> Tel: +1 703 879 1890
> www.isabelhealthcare.com
>  
> 
>  
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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