double whammy

Woods, David woods.2 at OSU.EDU
Mon Sep 28 16:13:11 UTC 2015


The conversation has stumbled into one of the fundamental technical issues.

First the basic technical issue.

Classification (or categorization) as a form of cognition is not diagnosis but only a small aspect of diagnosis. Diagnosis as a form of cognitive work is much much more than classification.  And if classification is confounded with the full range of diagnostic work cognitively, the result is a very crude and primitive reduction of the diverse aspects of cognitive work that are involved in diagnostic activities.

Simply put, classifying symptoms into categories is a very weak form of diagnosis — for many reasons, including: categorization is the crudest sort of model; symptom mapping is a very weak form of reasoning; time is ignored.  Furthermore, if classification is diagnosis and that is the end of the story, then no one could successfully manage anomalies in any dynamic process such as nuclear power emergencies, shuttle mission control, cardiovascular anesthesia, and many other settings.  Also, the neurobiology of anomaly recognition and of event recognition shows that detecting unexpected events or atypicality occurs early and guides later information processing in the brain. Next, the emphasis on classification creates an “unhealthy" separation between diagnosis and intervention. Complete models of cognitive work are organized around a set of relationships that cut across any divide between diagnosis and action — what you can do influences how you recognize and characterize the world (the simplest and most basic version is Neisser’s perception-action cycle from 1976 which is the standard reference in cognition and cognitive engineering though the concept goes back at least into the late 19th century).  The other related factor is — How you frame your world (and your relationship to that world) influences what you can see about that world.  Both framing and action possibilities change what you can see.  Finally, the key property of diagnostic work is the ability to revise.  The research shows that the issue isn’t the correctness of the leading hypothesis at any point in time per se, but rather the ability to revise as evidence comes in through proactive search, through new data becoming available, and through monitoring the response to interventions.  Many issues can mislead and influence diagnostic work toward assessments that turn out to be wrong based on later or a more complete set of evidence. The quality of the cognitive work ultimately depends on the answer to the question  — how well and how quickly can the system revise previous assessments as new evidence comes in that calls into questions those assessments.  A good example of revision breaking down occurred in the lead up to the Columbia Space Shuttle accident where evidence on the risks of foam strikes was discounted.

Mistaking classification for diagnosis is a misunderstanding of cognition.  Mistaking a piece of something as if it were the whole is a logical fallacy.  Mistaking is a dynamic interacting set of processes as if they were just a single mostly static process is one of the oversimplifcations or reductive tendencies (see Feltovich).  The pressure to categorize or build categorization into everything almost guarantees outbreaks of the reification fallacy (turning interacting processes into a thing by putting a name on them — see Stephen Jay Gould).

To be fair, the world of cognition and cognitive work is full of debates that arise when some schools of thought try to escape complexity by a reductionism that turns the rich and various interacting processes that underlie the label “diagnosis’ into a few simple steps.

Whammy #1
Conflating classification with diagnosis is (a) commonplace in medicine and (b) this error occurs throughout the IOM report, though along with sensible points such as premature closure.

Whammy #2
Billing codes are the worst form of reductionism about diagnosis, directly and indirectly, as the conversational thread points out.  Billing codes reduce to the crudest level possible all of the forms of cognitive work in diagnosis and the varieties of factors that influence the success or failure of these forms of cognitive work as evidence comes in over time.

The Double Whammy — mental lockdown on categorization and the contaminating effects of confounding finance and diagnostic work.
The world of health care has an extremely strong mental frame effect in this area.   The result is
(a) a muddle and jumble of concepts and analysis,
(b) unintended consequences of interventions that surprise and disappoint,
(c) vicious circle where each disappointment leads to further reductionism that takes the form of more pressures to reduce almost everything to categorization.

So what to do and how to move forward?

The IOM report highlights many areas of challenge, weaknesses, and opportunities. It provides an epidemiological argument for investments in improving care for patients.  But the epidemiological argument falls back into an over-reliance on thinking of diagnosis as classification.  The technical basis of diagnosis as cognitive work is both deeper and broader and it is highly sensitive to the huge diversity of different health care issues and settings.

Nevertheless, the IOM report represents a missed opportunity to break the mental lockdown and highlight how confounding of billing and medicine distorts patent care relative to this issue.  In any case, actually making progress on weaknesses, challenges, and opportunities will require a deep sensitivity to the full range of the technical basis of diagnostic work.


David



David Woods, Professor, PhD  木材
Releasing the Adaptive Power of Human Systems

• Lead, Initiative on Complexity in Natural, Social & Engineered Systems
• Co-Director, C/S/E/L Cognitive Systems Engineering Laboratory

[cid:82ddc142-9641-48ef-b01d-aa59b9196f3e at osu.edu]
Department of Integrated Systems Engineering
The Ohio State University
290 Baker Systems | 1971 Neil Ave Columbus, OH 43210
614-946-0123
woods.2 at osu.edu<mailto:woods.2 at osu.edu>

• Past-President and Executive Committee, Resilience Engineering Association

On Sep 27, 2015, at 5:35 PM, Ted.E.Palen at KP.ORG<mailto:Ted.E.Palen at KP.ORG> wrote:

In ICD 10
Cough R05
Right Knee pain M25.561
So I think general non- specific terms as of October are still possible but reimbursement rate for a general term maybe less than for a more specific condition.
And there in lies some of the problem, diagnostic data tied to billing terms rather than to actual clinical evaluation and decision making.

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 27, 2015, at 1:43 PM, "Swerlick, Robert A" <rswerli at emory.edu<mailto:rswerli at emory.edu>> wrote:

You may not be able to do that after October 1 because of ICD-10 deployment.



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: Ted.E.Palen at KP.ORG<mailto:Ted.E.Palen at KP.ORG> [Ted.E.Palen at KP.ORG<mailto:Ted.E.Palen at KP.ORG>]
Sent: Saturday, September 26, 2015 11:20 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] disappointed

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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-------- 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
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