Another look at Questions

Robert Bell rmsbell200 at YAHOO.COM
Thu Jan 7 16:21:29 UTC 2016


Thanks,

Important point.

But where are you if the diagnostic test is inaccurate and you make the wrong diagnosis?  Don't  you need to first look at all our testing, to have protocols to handle error, work to improve the test, or at least understand what we are dealing with. 

How many patients are on anti-hypertensives for life when they do not have hypertension? How inaccurate is a BP reading when taken, against recommendations, over clothing? And how often does that occur?

Rob

Sent from my iPad

On Jan 7, 2016, at 8:46 AM, Jason Maude <jason.maude at isabelhealthcare.com> wrote:

> Rob
> With healthcare I don’t think you have the luxury of focussing on the 'run of the mill' errors first. All are important if they seriously affect peoples lives. Anyway some people would say that we still haven’t sorted out hand washing after 150 years! 
> 
> I would also argue that diagnosis is the first and most important decision made about the patient that determines all subsequent care so how could you possibly put that aside till the 'run of the mill' errors are sorted out-which they won’t ever be!
> 
> Regards
> Jason
> 
> Jason Maude
> Founder and CEO Isabel Healthcare
> 
> 
> From: robert bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>
> Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, robert bell <rmsbell200 at YAHOO.COM>
> Date: Thursday, 7 January 2016 04:01
> To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> Subject: Re: [IMPROVEDX] Another look at Questions
> 
> Dear Michael,
> 
> Some good points. 
> 
> One of my thoughts is that we have the cart before the horse in first focussing on Errors in Diagnosis when something like 60% of errors are run of the mill standard errors. These such as communication problems that are associated with simple things like orders, wrong medications, computer problems, fatigue, education lack, and language problems. If we are truly interested in reducing the death toll and morbidity of Errors in Medicine as a whole should we not go for the jugular, identify the biggest problems, and tackle these collaboratively so that we get a significant reduction in the figures. 
> 
> And that brings up a big issue that first we need to have figures to be able to say if we are making progress. And think of the revolution that will create when we get into litigation and confidentiality discussions. That big question seems to be, can we do anything meaningful in either Standard and Diagnostic Errors without good data?
> 
> I take your point that a large percentage of lab and x-ray reporting is related to diagnosis, but it is also related to monitoring over time - INRs, mammograms, and bone density come to mind. I do not know the monitoring percentage but would guess it is 10 - 20% of the total.  As these two specialty areas are so important to the whole of medicine it would seem that the consortium of specialty societies (that incidentally should have patient representation) could triage the main problems in these areas and collaboratively work on improving them. From what I hear the electronic patient record would be something that should be looked at immediately. If you do not look after the important basic foundations of medicine and the standard 60% of all errors that accounts for the biggest mortality I believe that you are never going to effectively make inroads into the Diagnostic Error piece of the pie.
> 
> I am sure that with the benefits of technology there are many opportunities to reduce/improve the number of errors in both Radiology and Laboratory pathology.  And yes, you are correct radiology is likely to help make accurate diagnoses sooner than an impression made with a stethoscope (incidentally I have often wondered how accurate, in certain hands, the stethoscope is and have questioned what is its contribution to errors - perhaps it should be triaged close to the top!). But the technological advances in radiology would place it in the forefront for improvement of error rates.
> 
> So this does not mean that we should not be focussing on Diagnostic Errors as we move forward, but strongly believe we should first be making sure that the main foundations to diagnosis are as solid as they can be.
> 
> Yes, specialists with telemedicine links to help in the review process would be a wonderful idea to help with error rates.  And also a wonderful teaching tool to both specialist and radiologist. Could well be tried out with a small study if it is not already being done.
> 
> One of my thoughts is that in medicine that is structured hierarchically we may not be asking enough questions. Particularly as technology and collaboration is slowly eroding that hierarchy. Questions are often less intrusive and more than anything are creative in group settings. Questions should be encouraged in all meetings if we wish to make quick progress.
> 
> Do you think that Do and Don’t lists are of value?
> 
> Thank you Michael,
> 
> Rob Bell
> 
> 
>> On Jan 6, 2016, at 4:54 PM, Michael.H.Kanter at KP.ORG wrote:
>> 
>> interesting thoughts that you wrote below that are very thought provoking as usual.  Maybe I misunderstood but  you make the statement that " I felt that if there is a significant error rate in radiology reports and laboratory tests that this should be addressed first."
>> I personally consider error rates in radiology reports and lab tests within the scope of diagnostic errors and not sure why we would not address this quickly.   I do not believe that anywhere in the IOM report did they  suggest otherwise.    In fact, radiology report errors really fall into the class of diagnostic errors related to visual errors and also occur in pathology reports and other areas of diagnosis where the diagnosis is made by visual interpretation of an image.  We recently published a method on how to decrease these for interpretation of retinal photos  
>> Visual errors that are based on stored images (as opposed to looking at a skin lesion of a patient) have some advantages in terms of study and performance improvement including
>> 1) they are often stored in data systems for easy retrieval and identification
>> 2)  they can be retrospectively reviewed
>> 3)  one can determine the incidence of diagnosing a disease if the image or image results are stored in a data system and use the variation in diagnosis as a measure of diagnostic error/variability as was done in the attached paper. 
>> 4)  Diagnosis based on visual images can be more easily studied because  the variable of data acquisition can be controlled better (that is everyone can look at the same image/data) which is very different than a physical exam or patient history. 
>> 
>> My point is that it may be simpler to study errors due to visual interpretation of images than other types of diagnostic errors and this is something to consider addressing sooner rather than later.
>> 
>> I really like the idea of specialists societies getting involved in diagnostic errors.    Specialists  are likely to see such errors in their practice when referals are sent too late or with the wrong diagnosis.   
>> 
>> Michael Kanter, M.D., CPPS
>> Regional Medical Director of Quality & Clinical Analysis
>> Southern California Permanente Medical Group
>> (626) 405-5722 (tie line 8+335)
>> THRIVE By Getting Regular Exercise
>> 
>> NOTICE TO RECIPIENT:  If you are not the intended recipient of this e-mail, you are prohibited from sharing, copying, or otherwise using or disclosing its contents.  If you have received this e-mail in error, please notify the sender immediately by reply e-mail and permanently delete this e-mail and any attachments without reading, forwarding or saving them.  Thank you.
>> 
>> 
>> 
>> 
>> From:        robert bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>
>> To:        IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>> Date:        01/02/2016 04:03 PM
>> Subject:        [IMPROVEDX] Another look at Questions
>> 
>> 
>> 
>> Dear All, 
>> 
>> I would like to thank all the people on this list who kindly responded to my questions a few weeks back.
>> 
>> Since asking those questions I became aware that questions may be creative. 
>> 
>> Does it follow then that statements are less creative. I then thought how does that come about? 
>> 
>> A question I thought, stimulates listeners and readers to think of various solutions. So from one question you might get many solutions. With statements you would be more relying on the creativity of the writer presenting his or her various ideas and solutions. And these all together may not be great in number. 
>> 
>> With regard to the medical profession as a whole and people in positions of power in the healthcare industry who can effect change, one can ask do they ask fewer questions for fear of being considered less knowledgeable? So, if this is true, almost by definition, if questions are creative, such decision makers are less likely to be broadly creative, at least initially? There are obvious exceptions. So a  question might be how to better take advantage of the crowd think? 
>> 
>> This all makes an assumption that most things in medicine are complex and that many solutions to an issue may be necessary to arrive at a good solution.
>> 
>> The IOM has issued its statement/report on diagnostic errors and there are some good suggestions. I was pleased to see teamwork mentioned first in their solution. Which essentially is an extension of crowd think. 
>> 
>> But the big question is where do we go from here? As you all know I would have preferred standard medical errors to be approached first before diagnostic errors. For example, I felt that if there is a significant error rate in radiology reports and laboratory tests that this should be addressed first. But assuming that we may have the cart before the horse, and I am not completely sure about that, what questions could be asked of the established consortium of speciality societies?
>> 
>> Over and above the big structural solutions, what comes to mind for me is that some of these societies have issued Do and Don’t lists for their members.
>> 
>> So my new question is, could those lists be looked at and the idea extended to all the specialty societies with the emphasis on reducing diagnostic error?
>> 
>> Also, with any statement(s) would it be good to consider asking some questions at the end to stimulate thought?
>> 
>> The best for 2016, 
>> 
>> Robert M. Bell, M.D., Ph.C. 
>> 
>> 
>> 
>> 
>> 
>> 
>> 
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> 
> Robert M. Bell, M.D., Ph.C.
> P.O. Box 3668
> West Sedona, AZ  86340-3668
> USA
> 
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> To unsubscribe from IMPROVEDX: click the following link:
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> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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