disappointed

Joe Graedon jgraedon at GMAIL.COM
Sun Sep 27 13:03:08 UTC 2015


Here is a question Ted…speaking of coughs…

Our website has become a magnet for individuals who have been misdiagnosed because of an ACEi cough. We have heard from hundreds of people who have been worked up for allergies, asthma and goodness knows what else even though they were on a drug like lisinopril and complained of a persistent, uncontrollable cough. 

My questions are: 1) does any medical student NOT learn that ACE inhibitors cause cough and 2) why is this such a hard thing to diagnose? 

Here are just a few links so you can see for yourself:

Can ACE Inhibitors Cause Constant Coughing?
http://www.peoplespharmacy.com/2007/10/05/can-ace-inhibit/ <http://www.peoplespharmacy.com/2007/10/05/can-ace-inhibit/>

Ace Inhibitor Blood Pressure Pill Causes Cough
http://www.peoplespharmacy.com/2009/02/13/ace-inhibitor-b/ <http://www.peoplespharmacy.com/2009/02/13/ace-inhibitor-b/>

When Will Doctors Pay Attention to an ACE Cough?
http://www.peoplespharmacy.com/2010/04/26/when-will-doctors-pay-attention-to-an-ace-cough/ <http://www.peoplespharmacy.com/2010/04/26/when-will-doctors-pay-attention-to-an-ace-cough/>

Blood Pressure Meds Lead to All-Night Coughing
http://www.peoplespharmacy.com/2007/12/12/blood-pressure-1/ <http://www.peoplespharmacy.com/2007/12/12/blood-pressure-1/>

Pill Triggered Cough from Hell
http://www.peoplespharmacy.com/2010/04/05/pill-triggered-cough-from-hell/ <http://www.peoplespharmacy.com/2010/04/05/pill-triggered-cough-from-hell/>

Why Do So Many Doctors Ignore Obvious Drug Side Effects?
http://www.peoplespharmacy.com/2015/05/14/why-do-so-many-doctors-ignore-obvious-drug-side-effects/ <http://www.peoplespharmacy.com/2015/05/14/why-do-so-many-doctors-ignore-obvious-drug-side-effects/>


This is just a small sampling or articles on our website.

Joe Graedon




> On Sep 26, 2015, at 11:20 PM, Ted.E.Palen at KP.ORG wrote:
> 
> I often list a general diagnosis if I am unsure of a specific diagnosis. Such as, cough, instead of viral bronchitis, or knee pain instead of collateral ligament strain, if I am not sure of the more specific diagnosis.  
> 
> Ted E. Palen, PhD, MD, MSPH
> Physician Manager Clinical Reporting 
> Utilization Management
> Institute of Health Research
> Colorado Permanente Medical Group
> 10065 E Harvard Ave, Suite 300
> Denver CO  80231
> 
> Phone: 303-614-1215
> Fax: 303-614-1305
> email: ted.e.palen at kp.org <mailto:ted.e.palen at kp.org>
> 
> On Sep 26, 2015, at 8:50 AM, "Charlie Garland - The Innovation Outlet" <cgarland at INNOVATIONOUTLET.BIZ <mailto:cgarland at INNOVATIONOUTLET.BIZ>> wrote:
> 
>> 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 <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 <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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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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