Less life threatening differential diagnoses

Hamm, Robert M. (HSC) Robert-Hamm at OUHSC.EDU
Mon Aug 3 02:00:00 UTC 2015


Dr. Chengat,

It is not surprising that Dr. Ebell raises the question of sensitivity, specificity, likelihood ratio; that has been the language of those addressing this problem for decades. John Fox in the 1980's (now at Oxford) articulated the alternative, to have a non-probabilistic "possibilistic" logic, and based on expert opinion. It is fun that you have a working "diagnoser", as many of us do, but you need a full challenge test of it for the field to take it seriously.

Come to the Society for Medical Decision Making meetings in Saint Louis (Oct 20), or to the Society for Improvement of Diagnosis in Medicine, and talk with the attendees and develop a plan to provide an objective test for your product. I'll be at SMDM.

Rob


Robert M. Hamm, PhD
Clinical Decision Making Program
Department of Family and Preventive Medicine
University of Oklahoma Health Sciences Center
900 NE 10th Street
Oklahoma City OK 73104
405 271 5362 ext 32306       Fax 405 271 2784
robert-hamm at ouhsc.edu
________________________________
From: Vipindas Chengat [syncopesystem at GMAIL.COM]
Sent: Sunday, August 02, 2015 4:43 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Less life threatening differential diagnoses

Very interesting post. Addressing sensitivity/specificity/ LR or predictive values would pose another challenge. How would we calculate the base rate? Is it just the prevalence of the population or the clinic's population? How can we generalize those numbers? Mathematical strategy using Bayesian might not be the perfect method; but looking for patterns based on patho-physiological relations might be. That is how I built physician cognition's decision algorithm and it is doing very well( I think). It can even incorporate combined wisdom of professionals to optimize the decision rules ( you can find it here beta.physiciancognition.com<https://urldefense.proofpoint.com/v2/url?u=http-3A__beta.physiciancognition.com&d=AwMFaQ&c=qRnFByZajCb3ogDwk-HidsbrxD-31vTsTBEIa6TCCEk&r=xRJEBCjBmL1ypS8G4qfsiN0ww2Uty8FEqU-Ye79RFyM&m=dWtZoAwruRtTV7N8YZtLMsgFADwtOprtB7ideYXkT8o&s=m2UWyGNHgGZ68V3YgJoudkeLI9jpholQe4RUlimo1R0&e=>).
Dr. Ebell, if you would like to conduct any research to optimize decision pathways, I can provide it for free of cost. You can try any number of symptoms, signs and labs in any combination and system will provide differential diagnosis in the order of relevance, suggest further testing - can be a clinical sign, symptom or lab and decision tree will move forward based on answering those questions. You can also teach the system in real time or it can learn from a big database. Please let me know what you think. I think I have solved the very specific problem of combination of symptoms. I believe that if there are any sub-optimal results, it is just a matter of data and not the algorithm and can be solved within minutes.




Vipindas Chengat, MD FACP  |  Chairman, Physician Cognition, Inc.
  —————————————————————————————————
  Mobile: +1 (773) 575-3550
  Email: Vipin at PhysicianCognition.Com<mailto:Vipin at PhysicianCognition.com>
  Website: PhysicianCognition.Com<https://urldefense.proofpoint.com/v2/url?u=http-3A__physiciancognition.com_&d=AwMFaQ&c=qRnFByZajCb3ogDwk-HidsbrxD-31vTsTBEIa6TCCEk&r=xRJEBCjBmL1ypS8G4qfsiN0ww2Uty8FEqU-Ye79RFyM&m=dWtZoAwruRtTV7N8YZtLMsgFADwtOprtB7ideYXkT8o&s=vtWsYWMQIrtZ-8S7a6n0FrDfjt_zIWQa5ty-gD7CLAw&e=>

[cid:4B2F6648-AF44-49DB-BC58-D18DC6E96F85 at localdomain]

On Sun, Aug 2, 2015 at 4:08 PM, Mark H Ebell <ebell at uga.edu<mailto:ebell at uga.edu>> wrote:
While very useful in many ways, that approach would not address sens/spec/LR, would not help with acute problems, and would not address combinations of symptoms, at least not easily

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On Sun, Aug 2, 2015 at 9:47 AM -0700, "Jochanan Benbassat" <benbasat at jdc.org<mailto:benbasat at jdc.org>> wrote:


Unlike hospital based specialists, primary care physicians have the advantage of prolonged follow up of patients. Outpatient records offer the opportunity to determine the predictive value of abnormal syptoms and signs. In 1982 Dr Froom and I published in the BMJ the prevalence of microscopic hematuria in otherwise healthy male airpersonel aged 18-35 and the (negative) results of an average 7 years fillow up. I believe that a fsimilar ocus on the prevalence and outcomes of selected disease manifestations in the community after follow up offers an opportunity for such research



Jochanan Benbassat MD

Jerusaltm Israel

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From: Mark H Ebell [ebell at UGA.EDU<mailto:ebell at UGA.EDU>]
Sent: Sunday, August 02, 2015 16:21
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Less life threatening differential diagnoses

Blow up NIH. Well ok, not literally. The average age at first RO1 is now 40, and less than 1% of funding goes to what one could generously call primary care research. And none to study of clinical diagnosis. PCORI even expressly forbids research to develop and validate clinical decision rules. This research is not expensive, but proper reference standards (PCR, imaging) cost money.

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On Sun, Aug 2, 2015 at 5:19 AM -0700, "Robert Bell" <rmsbell200 at yahoo.com<mailto:rmsbell200 at yahoo.com>> wrote:

Excellent point. How to change things? What to do to get the funding?

Rob Bell

Sent from my iPad

On Aug 1, 2015, at 8:58 PM, Mark H Ebell <ebell at UGA.EDU<mailto:ebell at UGA.EDU>> wrote:

As a primary care physician, we often see diseases early in their course, when signs and symptoms overlap with other conditions and biomarkers may be negative (think lupus). Unfortunately, there is no funding in the US to study clinical diagnosis in the primary care setting, at least not as long as NIH is dominated by basic scientists and sub specialists. That would be the only way to identify the truly useful signs and symptoms (or more likely combinations).

Mark

—
Mark H. Ebell MD, MS
Professor of Epidemiology University of Georgia
Editor, Essential Evidence Deputy Editor, American Family Physician
ebell at uga.edu<mailto:ebell at uga.edu>


From: Carmel Crock
Reply-To: Society to Improve Diagnosis in Medicine, Carmel Crock
Date: Saturday, August 1, 2015 at 9:55 PM
To: "<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>"
Subject: Re: [IMPROVEDX] Less life threatening differential diagnoses

Dear Rob
I thought I would mention that at our Eye and ENT hospital emergency department, shingles is one of our commonest missed or delayed diagnosis, as patients present early with severe eye or ear pain but nothing (or little) to show on clinical examination.
Regards
Carmel Crock
________________________________
From: robert bell [<mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>]
Sent: Sunday, 2 August 2015 9:08 AM
To: <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] Less life threatening differential diagnoses

To me it seems that despite frequency patterns medical students are rightly taught at great length to focus on not missing the life threatening diagnosis. Is this done at the expense of missing the diagnosis with less dangerous competing conditions that are on the differential diagnostic list.

For example, how much do most medical students/residents know about shingles pain and symptoms prior to lesion development, with any lack of knowledge leading to the “diagnosis” of possible acute abdomen?

I would argue that in training knowing FAR more about the less dangerous differential diagnoses would get us more quickly to an accurate diagnosis, at possibly lesser cost.

So should there be in training more focus on the less serious competing differential diagnoses?

Rob Bell









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