SIDM's priority: Translating ideas into action

Alan Morris Alan.Morris at IMAIL.ORG
Mon Nov 9 15:50:55 UTC 2015


We need well-trained clinicians and that need is increasing.  However clinicians need help to do the job they, and the community, want achieved.

I believe the core problem is a cultural medical issue: we still cling tenaciously to the Hippocratic/Galenic model of care delivery that fosters the belief that “best care” is delivered only by a well-trained expert who makes the decisions after considerable all pertinent data.  This model fails us in modern medicine.

The unaided expert cannot consider all pertinent information for three reasons. 1-we have no systematic way of acquiring all pertinent information (particularly true for diagnostic reasoning, as Larry Weed has argued for decades); 2- human cognitive limitations make it impossible to do so (know by psychologists for over 60 years); 3-clinicians are overtasked and overburdened (the Institute of Medicine estimates the clinician’s day would have to increase from 8 hours to 21.7 hours if guidelines are followed).

The direct response to this core problem is development and application of detailed context-sensitive computer protocols that enable replicable clinician decisions, while providing personalized medical decisions (this has been show feasible for several medical problems during the past 3 decades).  Interestingly, closed-loop (automatic computer) control of two post-operative cardiac surgery tasks was successfully carried out in 8,500 consecutive cardiac surgery ICU University of Alabama patients and reported by Sheppard et al. in 1977.

There seems to be no funding agency interest in responding to this important clinician need.

Alan H. Morris, M.D.
Professor of Medicine
Adjunct Prof. of Medical Informatics
University of Utah

Medical Director, Urban Central Region Pulmonary Function Laboratories
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>
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From: Robert Bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Robert Bell <rmsbell200 at YAHOO.COM<mailto:rmsbell200 at YAHOO.COM>>
Date: Monday, November 9, 2015 at 08:30
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] SIDM's priority: Translating ideas into action

Good point.

Would there be benefit to having specific time related goals?

Do we need more action?

What could benefit patients most, and then start working on those things that seems doable?

The coalition could drive the process.

Rob Bell, M.D.



Sent from my iPad

On Nov 8, 2015, at 9:22 AM, Bob Latino <blatino at RELIABILITY.COM<mailto:blatino at RELIABILITY.COM>> wrote:

With so much of an abundance of literature and research in this niche space of thinking failures in clinical reasoning, over the past 35 years, why has there not been more progress in improving clinical decision-making today?

Sent from my iPhone

On Nov 8, 2015, at 7:11 PM, Pat Croskerry <<mailto:croskerry at EASTLINK.CA>croskerry at EASTLINK.CA<mailto:croskerry at EASTLINK.CA>> wrote:

Marius: it’s now about 35 years since the first direct studies of physician’s thinking failures in decision making (Detmer et al, J Med Ed 1978).  Over that period cognitive science has made huge advances in how we reason and make decisions. The gist of that work is that human reasoning, judgment and decision making is often a flawed process, and as Detmer et al noted: ‘A physician’s judgment is human judgment and susceptible to human limitations’ i.e. we are just as vulnerable as others. For evidence, start with the cognitive science literature. Typically, this is not read by the medical community but that is where much of the evidence lies (for references, see Croskerry Healthcare Quarterly 2012 and Croskerry Diagnosis, 2014). Examples of studies that have explicitly attributed cognitive factors (thinking failures) to failed diagnostic reasoning are Graber et al, (Acad Med 2002) Zwaan et al, (Arch Int med 2010). Estimates of ‘cognitive’ failure range from 70% to over 90%. A number of other studies were reviewed in Groopman’s popular book : How Physicians Think (2007). All of the major disciplines in medicine have now acknowledged the important role of thinking failures in clinical decision making(for references and suggested reasons for failing to recognize the problem see Croskerry, Diagnosis 2014).

On the second point for evidence of the effects of critical thinking you could start at the National Foundation for Critical Thinking website http://www.criticalthinking.org/  - coincidentally, also going for about 35 years. There are abundant references there on the beneficial effects of critical thinking. For the meta-analytic study I mentioned, see: Higgins et al, 2005 (A meta-analysis of the impact of the implementation of thinking skills approaches on pupils. In: Research Evidence in Education Library. London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London). This large study found that thinking skills were by far the most effective intervention for improving reasoning and problem solving. The study of pupils in the age range 5-16 years found a remarkable effect size of 0.62, the equivalent of moving a class from the 50th to the 26th percentile – an impressive gain of 24 percentile points. Medical undergraduates and postgraduates are beyond the age range of the group studied, however, from the limited studies on development of critical skills, there do not appear to be any temporal restrictions on when critical thinking interventions might be made.

For the ethical imperative to implement critical thinking into clinical reasoning, see the excellent paper by Stark and Fins (The ethical imperative to think about thinking. Diagnostics, metacognition, and medical professionalism.Cambridge Quarterly of Healthcare Ethics2014; 23: 386-396).
Pat


From: Marius Laurent [<mailto:marius.laurent at skynet.be>mailto:marius.laurent at skynet.be]
Sent: Thursday, November 05, 2015 11:35 AM
To: 'Society to Improve Diagnosis in Medicine'; 'Pat Croskerry'
Subject: RE: [IMPROVEDX] SIDM's priority: Translating ideas into action

Pat,
I like your proposition, but I must confess my surprise seeing your affirmation about numerous studies proving the role of thinking failure in diagnosis errors, and about meta-analytic studies demonstrating the efficacy of critical thinking training. I desperately look for such evidences, maybe you can help me?
Marius

De : Pat Croskerry [<mailto:croskerry at EASTLINK.CA>mailto:croskerry at EASTLINK.CA]
Envoyé : mercredi 4 novembre 2015 21:52
À : <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Objet : Re: [IMPROVEDX] SIDM's priority: Translating ideas into action


Mark: these all look worthwhile initiatives.

I’d like to add a further one: given that a number of studies now point to a significant proportion of diagnostic failure being due to thinking failures, and given that meta-analytic studies demonstrate conclusively that by far the most effective way of improving reasoning and problem solving skills is through critical thinking interventions, I advocate for the introduction of critical thinking interventions at UGME and PGME. Others have already designated critical thinking as a meta-competency and some programs have embarked on this in separate initiatives. Others in the ethics domain have strongly proposed that this be done as an ‘ethical imperative’, and, given the unacceptably high estimates of preventable deaths from diagnostic failure it’s hard to argue with that.

Rather than each inventing our own wheels, how about developing a generic Critical Thinking Module that would be available off the shelf that medical educators could use? The content could be approved by a consensus committee. This would be an inexpensive project with potentially high returns.

Pat


On 11/04/15 12:43 PM, Mark Graber <mark.graber at IMPROVEDIAGNOSIS.ORG<mailto:mark.graber at IMPROVEDIAGNOSIS.ORG>> wrote:
With the IOM report now officially out on the street, SIDM is now focused on how to change practice to improve diagnosis.  The "Coalition to Improve Diagnosis" will be our first priority; the Coalition steering committee has had several meetings already, and the next steps are for each organization to identify at least one action they can take, and for all the members to agree on a common action. The Coalition will also be growing very soon to include another set of key national organizations.

We are also urging federal agencies to step up to the plate.  Founding Board member David Newman-Toker represented SIDM at a meeting yesterday of the AHRQ National Advisory Committee, and publicly thanked AHRQ for being a key supporter of our efforts through funding of our Diagnostic Error Conferences, the IOM report itself, and through the new R01 and R18 grant funding to study diagnostic error they have recently made available. We asked the NAC to support 3 initiatives deriving from the IOM report:  1) Developing a Common Format for organizations to report diagnostic errors to their Patient Safety Organizations; 2) Working with DOD, HHS, VA and others to develop the national research priorities for diagnosis, and to develop a public-private partnership to promote research; and 3) Providing dedicated funding for AHRQ to support research on diagnostic error in proportion to the harm associated with diagnostic error.

Later this month I'll be addressing a group at the CDC to emphasize the actions we'd like to see them take: 1) Resurrect the clinical pathologist position by providing funding for this type of consultation; 2) Resuscitate autopsies at key designated centers as a way to learn about errors; 3) Help develop and use failsafe procedures for test reporting; and 4) Use second opinions in anatomic pathology.

We'll provide updates on these activities as they come up, and would love to hear about initiatives that the listserv readership might also know about, or be involved with.

  Mark

Mark L Graber MD FACP
President, SIDM  <http://www.improvediagnosis.org> www.improvediagnosis.org<http://www.improvediagnosis.org>
919 990-8497
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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