disappointed

Hamm, Robert M. (HSC) Robert-Hamm at OUHSC.EDU
Sat Sep 26 18:28:04 UTC 2015


I think this argument is misguided, at least as a general argument for most medical situations. It might make sense in the context of genetic diagnosis.
There is long awareness that the “digital”, that is, “binary”, yes/no nature of clinical treatment decisions should be related to the comparison of the benefits of appropriate treatment and the harms of inappropriate treatment, which can be summarized as a treatment threshold: a point prescribed on the degree of uncertainty, at which the binary treatment decision should switch to “yes”.
Pauker and Kassirer 1975 and 1980 put that out explicitly. To assert that “medicine is digital” and hence to consider and state a degree of certainty is irrelevant is both a mistake, and an ignoring of a well justified perspective that every physician should be familiar with.

Rob Hamm

From: Kodolitsch von, Yskert [mailto:kodolitsch at UKE.DE]
Sent: Saturday, September 26, 2015 10:11 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: [IMPROVEDX] AW: [IMPROVEDX] disappointed

„labelling diagnoses according to certainty“ is probably not a smart idea. The problem is that clinical decisions require digital information rather than analogue information. You may see this argument specified in our article in the attachment to this mail.
Best,
Yskert

Von: Charlie Garland - The Innovation Outlet [mailto:cgarland at INNOVATIONOUTLET.BIZ]
Gesendet: Freitag, 25. September 2015 17:54
An: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Betreff: Re: [IMPROVEDX] disappointed

Mark, you (and others here) bring up an outstanding point.  Imagine for a minute what would happen if the EMR screen suddenly had a data entry field for a "degree of certainty" value (percentage) next to the ICD code.  Would this not compel the physician to think just a bit more carefully -- at that very moment -- about just how confident he/she is about the Dx?  And, wouldn't that then (some portion of the time) trigger the contemplation of at least one alternative DDx?

Now, imagine that "confidence field" being gone (which it is).  Isn't the implicit assumption here that the diagnostician is 100% confident of his/her diagnosis?  Whether or not this is how anyone might intend or infer the EMR data, in some cases, that is the way it's regarded.  Considering what Brian Jackson mentioned, in some portion of cases, there is clearly a degree of uncertainty that is in the mix.  And that data value -- regardless of how accurately it can be captured -- is something that seems likely to improve the prospects of patient safety, over the long haul at least.

It would be an interesting research study to see what would happen if an institution's EMR system explicitly offered an additional field or two (confidence interval, most likely DDx, etc.).  How would physicians respond to this, over time?  What might be the implications of that additional data -- and the "forcing strategy" effect it would possibly have on diagnosticians (and others accessing the same data) -- upon Dx error rates?

Just one opinion.

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Charlie Garland, President

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-------- Original Message --------
Subject: Re: [IMPROVEDX] disappointed
From: Mark Graber <graber.mark at GMAIL.COM<mailto:graber.mark at GMAIL.COM>>
Date: Thu, September 24, 2015 8:12 pm
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>

I'm seconding Brian Jackson's suggestion to move towards attaching levels of certainty to each diagnosis.  I'm especially fond of the "NYD" label Sam Campbell had on his list of the 10 best things to have happened in the field of emergency medicine in Canada.   NYD = not yet diagnoses.  This would alert the next person in the chain to keep thinking !   If we only had an ICD-10 code for that …..

On Sep 24, 2015, at 10:32 AM, Jackson, Brian <brian.jackson at aruplab.com<mailto:brian.jackson at aruplab.com>> wrote:

We might want to be careful about this one.  From a research perspective, analyzing time to diagnosis would indeed be interesting and productive.  But if in the process we give regulators, payors and attorneys new ways to punish delays at an individual physician level, it could amplify premature closure and overdiagnosis.

A suggestion others have brought up, and I suspect this needs to be pushed more aggressively, is the concept of explicitly labeling diagnoses with their level of certainty, e.g. as tentative or working diagnoses where appropriate.  Sometimes empiric therapy is the best way to proceed.  When empiric therapy fails, it doesn’t necessarily mean the diagnostic process failed, i.e. that a diagnostic error occurred.

Many of the complications introduced by both medicolegal and quality improvement efforts come from treating diagnosis as a black and white situation.  As much as I like the current news coverage of the IOM report, it’s reinforcing that black/white perspective.

--Brian Jackson

From: robert bell [mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG]
Sent: Wednesday, September 23, 2015 3:25 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] disappointed

But our foot is in the door.

Also, as we get more information on Time to Diagnosis, it would seem that there could be a kind of “standard time to diagnosis,” for less common diseases/conditions that could be adjusted from time to time as we get more proficient (e.g. for myasthenia gravis), perhaps even adjusted in some way for the medical sophistication of the medical center in question!

Do we need to talk about standards for what is a delayed diagnosis?  Or maybe that has already been discussed.

Just publishing a list of the common conditions we THINK are diseases of delayed diagnosis would be a start.

Rob Bell, M.D.


On Sep 23, 2015, at 11:19 AM, Michael Grossman <Michael.Grossman at MIHS.ORG<mailto:Michael.Grossman at MIHS.ORG>> wrote:

I agree with your assessment. The IOM sometimes seems to fall short of expectations. Their relatively recent report on Graduate Medical Education was disappointing.
The fact that multiple news agencies are running with this story may lead to some misunderstandings , especially on the nature of "delayed diagnoses".
Michael Grossman, MD MACP

-----Original Message-----
From: Robert L Wears, MD, MS, PhD [mailto:wears at UFL.EDU]
Sent: Wednesday, September 23, 2015 9:31 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] disappointed

Great that misdiagnosis and related failures are getting attention, but ...

This is a disappointing effort; a naïve, keyhole view of a complex problem.

I count 82 mentions of 'error' in the first 15 pages (~5.5 per page), 753 in the entire document.

Lots of discussion about biases (78 mentions) but important issues that challenge the focus on 'error', such as hindsight bias, or outcome bias, are never mentioned even once.

This restriction to a very narrow framing of the problem is unlikely to lead to progress.

bob



Robert L Wears, MD, MS, PhD
University of Florida              Imperial College London
wears at ufl.edu<mailto:wears at ufl.edu>                        r.wears at imperial.ac.uk<mailto:r.wears at imperial.ac.uk>
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