disappointed

David Hallbert david.hallbert at GMAIL.COM
Thu Oct 1 09:23:16 UTC 2015


John, are you familiar with PKC--now AskMD?  It's based on Larry Weed's
work and has patients (not MD's) go through lists of questions about their
symptoms and then organizes the symptoms based on diagnosis that have those
symptoms and ranks them in terms of severity (so not to miss urgent,
serious dx) and then on the number of sxs that go with each diagnosis.  I
used to sit in from of a screen with a patient and have to go through a
lengthy "differential diagnosis" list that was far more detailed than most
physicians can possibly conjure.  Within each dx was a short discussion in
patients' language about the dx, the specifics of the symptoms with that
diagnosis and also what dx were missing were this what the patient had.  It
was an amazing experience and both patient and MD left the discussion
feeling the condition had been much more completely explored.  Having a
computer generate such a list and gather information cut out so much bias
and potential diagnostic error has been available for years and now is
available free to patients on Sharecare.  I've looked at Art Papier's site
as well and those two programs at least offer a much better opportunity at
having a much broader view of diagnostic possibilities for experienced as
well as inexperienced diagnosticians to have to consider.

David M. Hallbert, MD
Martins Point Healthcare, Bangor
650 Evergreen Woods
700 Mt Hope Ave
Bangor ME
207-945-5048
david.hallbert at martinspoint.org

On Sun, Sep 27, 2015 at 1:48 AM, John Brush <jebrush at me.com> wrote:

> I agree with Art Papier about problem lists. I think that better use of
> the problem list is one of 2 things that could have immediate impact on
> improving diagnosis in medicine.
> Both Art and I trained at University of Vermont under Larry Weed. We were
> taught that a problem list should be dynamic. Problem statements can be
> provisional, temporary, active, permanent, inactive, or resolved. And the
> problem statement can change form day to day, becoming more specific as the
> diagnostic process proceeds. For example, “shortness of breath” can become
> “congestive heart failure” and then become “acute systolic heart failure”
> as new information is added and the diagnosis is re-evaluated through
> iterative hypothesis testing.
> I think we need to be much more attentive to the logic, syntax and
> semantics of problems statements so that they are as clear and unambiguous
> as possible. And having a complete list of evolving provisional problem
> statements can sometimes cause the practitioner to recognize a
> constellation of problems that unify into a single diagnosis.
> By the way, the other thing that will improve diagnosis is using
> likelihood ratios as a tool to teach trainees how to place the proper
> weight on clinical cues.
> John
>
> John E. Brush, Jr., M.D., FACC
> Professor of Medicine
> Eastern Virginia Medical School
> Sentara Cardiology Specialists
> 844 Kempsville Road, Suite 204
> Norfolk, VA 23502
> 757-261-0700
> Cell: 757-477-1990
> jebrush at me.com
>
>
>
> On Sep 25, 2015, at 4:42 AM, Art Papier MD <apapier at LOGICALIMAGES.COM>
> wrote:
>
> This area of what and how an assessment is made and charted is an area
> that the SIDM community should work with AMDIS (CMIO)/AMIA communtiy to
> issue a recommendation as soon as possible.  Too often clinicians
> expediently write a thin assessment and expediently put in an ICD
> tentative diagnosis that erroroneously becomes THE diagnosis.  In my
> clinic yesterday afternoon we saw a patient that had a single dystrophic
> nail and distal finger edema.  The problem had been going on for years.
> The patient had previosuly been treated for onychomycosis.  During the
> visit i noticed she was constantly manipulating the finger as we talked.
> We had a discussion that her problem might be due to this unconcious
> habit.  She agreed.  The plan that was recommended was to do a fungal
> culture, and for her to keep the finger bandaged and to not manipulate or
> rub or touch that distal finger, then to come back in a couple months.  We
> use Epic, Our residents chart and i review the notes at the end of clinic
> or within 24 hours.  Yesterday late i reviewed the note for the patient.
> The assessment was one word "onychomycosis".  I sent the resident a note
> through the EHR system that the assessment was not simply onychomycosis
> and asked her to change the note to reflect what we discussed.  The
> resident used an ICD 110.1  which means "onychomycosis".  How often do
> physicians use the expedient ICD?  I know i typically do not enforce
> preceision with it, (it takes too much time) We desperately need a code
> that says NYD (or equivalent)  so that we do not expediently place one of
> the diagnoses that is in the differential, but is NOT with certainty the
> diagnosis.  Furthermore a good assessment will explain the "basis" for the
> diagnosis.  I rarely see these in a note, even when the diagnosis is
> tentative. Since many patients are not seeing the same physician in
> follow-up in some care situations, having an accurate note becomes even
> more important in preventing diagnostic error.   Larry Weed has written
> about what a good note is and the idea of having a "basis" for a
> diagnosis.  The ICD and CPT billing system has a systemic flaw in what it
> encourages,  which is imprecision and expedience.  We desperately need for
> our community to come together with the informatics community and the
> ONC/HHS to create a coding system that encourages to note in the EHR that
> we are not sure yet when we do not have a basis for the diagnosis.
>
> PS For those that watched the IOM presentation.  A question was read from
> the podium alledgedly emailed in by Larry Weed about the role of computers
> and decision support systems in fixing diagnostic error.  I spoke with
> Larry this week.  Interestingly he did not watch the IOM presentation and
> was quite puzzled and a bit upset that someone would email in and
> represent themselves as him.  He asked "Why would someone do that?" That's
> a good question!
>
> Best Art Papier MD
> Asssociate Professor of Dermatology and Medical Informatics University of
> Rochester, CEO VisualDx
>
>
>
>
> 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>
> 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
> <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>]
> Sent: Wednesday, September 23, 2015 3:25 PM
> To: 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 <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 <wears at UFL.EDU>
> <mailto:wears at UFL.EDU <wears at UFL.EDU>>]
> Sent: Wednesday, September 23, 2015 9:31 AM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> <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 <wears at ufl.edu>>
> r.wears at imperial.ac.uk <mailto:r.wears at imperial.ac.uk
> <r.wears at imperial.ac.uk>>
> 1-904-244-4405 (ass't)            +44 (0)791 015 2219
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> Suite 240
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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