Diagnostic errors related to acute abdominal pain in the emergency department.

Hamm, Robert M. (HSC) Robert-Hamm at OUHSC.EDU
Mon Nov 23 05:27:14 UTC 2015


Hands, voice and eyes.
I.e., don't look only at the computer screen, look at the person.

From: Harold Lehmann [mailto:lehmann at JHMI.EDU]
Sent: Sunday, November 22, 2015 5:31 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Diagnostic errors related to acute abdominal pain in the emergency department.

Are there data that patients need the touch of hands in order to feel that they are being cared for or are being healed? This is the non-informational component of the physical exam.

Harold

From: "Follansbee, William" <follansbeewp at UPMC.EDU<mailto:follansbeewp at UPMC.EDU>>
Reply-To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, "Follansbee, William" <follansbeewp at UPMC.EDU<mailto:follansbeewp at UPMC.EDU>>
Date: Friday, November 20, 2015 at 2:12 PM
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] Diagnostic errors related to acute abdominal pain in the emergency department.

The various thoughts reflected in this string are interesting and valid, but as a cardiologist I have a little different perspective. We had a recent medical education grand rounds that debated the question of whether the physical exam is still relevant.  All present agreed that a careful history remained the best diagnostic test that we have. For the average well person annual checkup, that history likely can be done very quickly and, since the population is likely healthy, the yield will be low. For patients presenting with symptoms, however, it is quite different. This history then becomes quite valuable. Depending on the nature of the symptom and the context in terms of the specific patient, that history might be very focused, or it might be much broader. There was one comment that specialists tend to do only very focused histories. While that might be true, it is an over-generalization in that not infrequently, the most detailed histories are also done by specialists. Regardless of who performs it, the history remains an enormously valuable diagnostic tool.

There is more debate about the physical exam. Some of the variability may be "the nature of the beast," but a lot of it is the lack of skill of the observers, which gets back to education and training. Some at the grand rounds were advocating for universal use of pocket ultrasound devices, largely to replace the traditional physical exam. However, the accuracy and reproducibility of using a very low cost, low resolution imaging device by observers who have minimal training and experience is unclear. Even with high cost, sophisticated echocardiography machines, done by trained technologists and read by experts, there is a tremendous amount of variability. More importantly, however, when we begin to take care of images of patients, we lose knowledge and sophistication in physiology and pathophysiology which is essential to doing a competent physical examination. Few residents today can even define what a mid-systolic murmur is, let alone knowing why that is important in differentiating etiology. That knowledge of pathophysiology, which is best linked at the bedside, is critically important to reducing both diagnostic and therapeutic errors.  More and more, as we react to images of patients out of context from the competent bedside H&P, diagnostic errors are increased and are more likely to go unrecognized, and inappropriate therapeutic decisions  not uncommonly ensue.

William P. Follansbee, M.D., FACC, FACP, FASNC, FAHA
The Master Clinician Professor of Cardiovascular Medicine
Director, The UPMC Clinical Center for Medical Decision Making
Suite A429 UPMC Presbyterian
200 Lothrop Street
Pittsburgh, PA 15213
Phone: 412-647-3437
Fax: 412-647-3873
Email: follansbeewp at upmc.edu<mailto:follansbeewp at upmc.edu>


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From: Mark H Ebell [mailto:ebell at UGA.EDU]
Sent: Friday, November 20, 2015 1:38 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Diagnostic errors related to acute abdominal pain in the emergency department.

So, for an asymptomatic person coming in for a health maintenance exam, the history is very important, while the physical examination is incredibly unhelpful. Take the routine skin exam. Even a large state level quasi-experimental/ecologic study in Germany found 1 fewer melanoma death/100,000 in the group that had annual skin exams encouraged. And that study was riddled with potential biases, so this is probably an overestimate of benefit.

On the other hand, for a symptomatic patient with leg or abdominal or chest pain, intelligent use of the physical exam can help us select tests, etc. But I'm continually amazed at just how inaccurate individual findings are. At best, they are helpful at risk stratification when used together as in the Wells rule for PE.

Mark

-
Mark H. Ebell MD, MS
Professor of Epidemiology
University of Georgia
Editor, Essential Evidence
Deputy Editor, American Family Physician
ebell at uga.edu<mailto:ebell at uga.edu>


From: "Ely, John" <john-ely at UIOWA.EDU<mailto:john-ely at UIOWA.EDU>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, "Ely, John" <john-ely at UIOWA.EDU<mailto:john-ely at UIOWA.EDU>>
Date: Friday, November 20, 2015 at 11:54 AM
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] Diagnostic errors related to acute abdominal pain in the emergency department.

We're not supposed to do complete physical exams anymore.  (http://www.nytimes.com/2015/01/09/opinion/skip-your-annual-physical.html?_r=2<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.nytimes.com_2015_01_09_opinion_skip-2Dyour-2Dannual-2Dphysical.html-3F-5Fr-3D2&d=BQMF-g&c=qRnFByZajCb3ogDwk-HidsbrxD-31vTsTBEIa6TCCEk&r=xRJEBCjBmL1ypS8G4qfsiN0ww2Uty8FEqU-Ye79RFyM&m=_nSm1f3cawwdgW3wPfLFRM6i-B4mQoIujqkbKjzZYhA&s=_Lz6AL3nRNTsOf9J0n9qJOcXG56bRheQFRnyVuMaYGY&e=>)

Next thing you know, they'll tell us complete histories are also "worthless" or at least not evidence based.

However, I still think we should do both.

John Ely, MD
University of Iowa



From: Bruno, Michael [mailto:mbruno at HMC.PSU.EDU]
Sent: Friday, November 20, 2015 9:52 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Diagnostic errors related to acute abdominal pain in the emergency department.

Thanks, Julianne, Thanks Ruth.

I'm convinced that a great many diagnostic errors could be avoided by simply improving the quality & comprehensiveness of the H&P.  At our institution, specialist physicians will typically only elicit a focused history within their proscribed purview, and then go on to physically examine only their own small bit of "territory."  My own PCP has also never done a complete H&P on me, and I've been seeing him for years!  It seems to me that the only people who actually perform a comprehensive "top to bottom" H&P anymore are the medical students (who pay us for the privilege).

All the best,

[Description: Description: Description: \\hersheymed.net\files\Staff\M\mbruno\Signature2.gif.gif]
Michael A. Bruno, M.D., F.A.C.R.
Professor of Radiology & Medicine
Vice Chair for Quality and Patient Safety
Chief, Division of Emergency Radiology
The Milton S. Hershey Medical Center
Penn State College of Medicine
500 University Drive, Mail Code H-066
Hershey, PA  17033

Phone: (717) 531-8703
Fax:      (717) 531-5596

e-mail: mbruno at hmc.psu.edu<mailto:mbruno at hmc.psu.edu>


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Thanks

From: Julianne Nemes Walsh [mailto:nemeswalsh at GMAIL.COM]
Sent: Friday, November 20, 2015 10:28 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Diagnostic errors related to acute abdominal pain in the emergency department.

Thank you Ruth, the data consistent with malpractice claim data findings and certainly an area of focus for preventative educational strategies.

On Thu, Nov 19, 2015 at 5:34 PM, Ruth Ryan <ruthryan at cox.net<mailto:ruthryan at cox.net>> wrote:
I can't get to the whole article, but here is a link to the abstract.  http://www.ncbi.nlm.nih.gov/pubmed/26531859<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.ncbi.nlm.nih.gov_pubmed_26531859&d=BQMF-g&c=qRnFByZajCb3ogDwk-HidsbrxD-31vTsTBEIa6TCCEk&r=xRJEBCjBmL1ypS8G4qfsiN0ww2Uty8FEqU-Ye79RFyM&m=_nSm1f3cawwdgW3wPfLFRM6i-B4mQoIujqkbKjzZYhA&s=0-15_X2ZesdIzl5Ep1XNkGhRDe-P_tNQOgr-nmad00w&e=>
Medford-Davis L, Park E, Shlamovitz G, Suliburk J, Meyer AN, Singh H. Diagnostic errors related to acute abdominal pain in the emergency department.
Emerg Med J. 2015 Nov 3. pii: emermed-2015-204754. doi: 10.1136/emermed-2015-204754. [Epub ahead of print]
Of interest, over 1/3 of high risk abdominal pain pts in the ED in this study had diagnostic errors. The most commonly missed diagnoses were gall bladder disease and UTI, confirming once again that it tends to be the most common diagnoses, not the rarest that are misdiagnosed.
2/3 of the cases had breakdowns in the diagnostic process, most often

*        history-taking

*        ordering insufficient tests

*        problems with follow-up of abnormal test results

Ruth

Ruth Ryan RN, BSN, MSW, CPHRM
Medical writer
Risk management/patient safety
Continuing medical education
Telephone (504) 256-8797<tel:%28504%29%20256-8797>
Email ruthryan at cox.net<mailto:ruthryan at cox.net>
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