Less life threatening differential diagnoses

Alan Morris Alan.Morris at IMAIL.ORG
Mon Aug 3 02:17:22 UTC 2015


Is your algorithm linked in any way with Larry Weed’s strategy and his knowledge couplers?
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<tel:801-507-4603>
Mobile Phone: 801-718-1283<tel:801-718-1283>


From: Vipindas Chengat <syncopesystem at GMAIL.COM<mailto:syncopesystem at GMAIL.COM>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Vipindas Chengat <syncopesystem at GMAIL.COM<mailto:syncopesystem at GMAIL.COM>>
Date: Sunday, August 2, 2015 at 19:57
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<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

Excellent questions. Here are my thoughts.

1. With fever and cough, how much likely does the patient have pneumonia.

 What if the answer is 76%? For epidemiological data for an ER or an insurance company, it is a valid information. But, for a clinician, he/she has only one patient at a time and does not know if that patient belongs to 76% or 24 % or 5%. So, how can this be a relevant number unless he/ she has gathered all relevant clinical information for that combination of symptoms?

2. What if the cough is chronic and fever is intermittent for months? What if the patient has fever, cough, night sweats, weight loss and lymphadenopathy? Or fever for two days and cough for months? To consider every single possibility, how many patients should be studied and for how long?

3. Say, if the patient has cervical lymphadenopathy and analysis has shown that there is 5% chance of having lymphoma. What does that 5% mean? Whether the physician should do biopsy or wait? Whether the patient be happy or unhappy as the number can be perceived as high or low depends on individuals. Rather, shouldn't the physician try to gather data like the size and consistency of the LN, presence of systemic signs etc?

4. Our algorithm create dynamic checklists. Example: What if fever and cough has started after chest trauma or an episode of seizure? These are specific contexts that are relevant for that combination. It can also look for other symptoms like purulent sputum or hemoptysis or unilateral leg swelling.

5. The study that you have mentioned can be used for one diagnosis at a time. However, what if there are hundreds of diagnoses for a combination of symptoms? Example, if you suspect PE, you can calculate pre test probability and then order d dimer or CT angiogram or VQ scan and evaluate the post test probability based on the performance characteristic of the test. However, is PE missed due to lack of awareness of the literature or inability to consider it for uncommon presentations like unexplained tachycardia? Is diagnosis missed due to lack of availability of data based on multivariate analysis or inability to see patterns and inability to gather all the relevant clinical data before making diagnostic assumptions?

6. If I input fever and cough for a 40 year old man, my algorithm considers all the possible causes- several hundreds and list them in the order of relevance. How does it test for relevance? How do we get the pre- test probability ? Well, even practicing physicians don't know what the exact pre test probability is. We don't try to solve it purely mathematically. We aren't rounding with tables with LRs and sensitivity/ specificity. But, we do have an understanding that some are common and some are rare. Some symptoms and signs and very specific and some are not. To consider certain diagnoses, we absolutely need certain symptoms. We know what questions and to ask and try to find patterns that are relevant based on patho-physiology. Then we look for certain signs that are highly suggestive of certain diagnoses. Or we do a test that can be used to significantly reduce the possibility of certain conditions. In brief, this is what my algorithm is doing. We have identified about 50-60 relations between a symptom or sign or lab test and a diagnosis and try to apply it simultaneously. We believe that if the system can create dynamic check lists for any random combinations, it will improve the performance and consistency in decision making. If we can get structured studies like you mentioned that gives us precise numbers; we can plug that information into my algorithm to improve its performance. However, can we use the same number for different populations in a different demographic regions?

My humble attempt with the algorithm is to solve a complex problem with a simple method. Like, catching a fly ball by keeping the angle to the ball constant rather than using calculus. But the option to use the numbers are kept open. However, we had only limited success when we used predictive analytics from a big database compared to current patho-physiologic algorithm.

Vipin




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<http://physiciancognition.com/>

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

On Sun, Aug 2, 2015 at 4:59 PM, Mark H Ebell <ebell at uga.edu<mailto:ebell at uga.edu>> wrote:
The question I”m asking is: “In patients presenting with <symptoms x>, how accurate is <sign/symptom/combination> for the diagnosis of <disease y>”. For example, “In patients with acute RTI, how accurate are fever, cough, and combinations of symptoms for diagnosis of influenza? (or pnuemonia?)”

Not familiar with your database, but to answer these questions you need:

  1.  A moderately large group of patients with a clinically relevant spectrum of disease (I.e. Patients presenting to a primary care doc or ER with undifferentiated acute RTI)
  2.  A prospective assessment of a range of signs and symptoms
  3.  An accurate reference standard test (in this case PCR) given to all patients

Clinical decision rules are typically developed using this kind of data and using multivariate analysis to identify the optimal set of predictors.

Best,

Mark

From: Vipindas Chengat
Date: Sunday, August 2, 2015 at 5:43 PM
To: Society to Improve Diagnosis in Medicine, Mark Ebell

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<http://beta.physiciancognition.com>).
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<http://physiciancognition.com/>

[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

________________________________

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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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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