Another look at Questions

Art Papier apapier at VISUALDX.COM
Fri Jan 8 18:47:13 UTC 2016

There are many diagnoses that are clinical diagnoses alone.  No lab tests or radiologic studies are part of the standard of care.   In dermatology we make clinical diagnoses all day long, and we see cognitive mistakes by PCP’s every day.  The limitation is the primary care physician’s knowledge and their ability to do an excellent skin exam, describe the exam and make an accurate differential diagnosis.  These mistakes are cognitive.  As an example, there are 500,000 admissions for cellulitis every year.  Roughly 30% of these admissions are completely unnecessary.  That’s over 1 billion dollars in wasted healthcare dollars.  Worse is the harm from unnecessary antibiotics resulting in life threatening problems such as C diff and drug reactions such as TEN or Stevens Johnson.   Premature closure on the red leg being cellulitis is the issue.  The failure to diagnose stasis dermatitis, panniculitis, gout, herpetic infections etc..  are cognitive mistakes.  1 diagnosis alone is costing US healthcare over 1 billion dollars each year in waste and there is no biopsy or lab test that makes this diagnosis.   The IOM report placed a great deal of responsibility on the patient, and IMO too little was placed on the physician for not knowing.   Furthermore I would add that choices in testing and diagnostic imaging study follow a good differential diagnosis.

Art Papier MD

CEO VisualDx

Associate Professor of Medical Informatics and Dermatology

University of Rochester College of Medicine


From: robert bell [mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG] 
Sent: Friday, January 08, 2016 12:10 AM
Subject: Re: [IMPROVEDX] Another look at Questions


Thank you.


Thanks for your support regarding questions being creative.


My thinking is to that it is going to be very difficult to tackle Errors in Diagnosis without first tackling General Errors Including all diagnostic tests. So many general errors impact the diagnostic process. 


The Consortium should be able to handle both being drawn from many Specialty Societies.


There is the possibility that research and recommendations in both standard and diagnostic errors could overlap in time or be done together. diagnostic error research and discussion should continue in an unfettered way. 


But the foundations of Medicine need to be strong to get to the right diagnoses more often. I do not think they are strong now. With the error rates in radiology and laboratory tests, the use of stethoscopes by some with big error rates, the poor use of sphygmomanometers, communication problems in general, etc., etc. 


All need to addressed and corrected or fully understood before there is any good chance of feeling comfortable with any new diagnostic advances. 


Glad that you think that Do and Don’t lists have some value. Those could be started tomorrow!


I suggest triaging the problem areas in general and diagnostic errors, first based on mortality and morbidity estimates and maybe even, to make an impression on the statistics, by including the a few of the leading general errors in US hospitals.


I am very concerned that nothing will happen as we need to understand if we are making progress and that needs accurate data collection and the decision makers do not like that such data. 


I would welcome your thoughts and those of people on the list as to how they think this major problem could be tackled? For me it is the number one barrier to progress.


Yes, trusting that 2016 will be a banner year for the Society with significant progress made.








On Jan 7, 2016, at 9:12 AM, Charlie Garland - The Innovation Outlet <cgarland at INNOVATIONOUTLET.BIZ> wrote:


Rob - Thanks for this prompt and a very happy new year to you.


A few thoughts come to mind in response to your post.  First of all, I am sure that questions -- in general -- can be an extremely valuable source of creativity.  Why?  Because they serve as a stimulus to change the thought process of the questionee (he or she to whom to question is being posed).  That thought process may or may not already be on the right track...but at the times when it is not (e.g. via early/premature closure bias), the question may in fact interrupt the "pattern recognition" that could lead to an incorrect Dx.


We spend the vast majority of our time thinking in System 1 mode (for those who acknowledge the dual process theory espoused by Daniel Kahneman and others), which is more routinized and relatively less "conscious" than a robust System 2 cognitive process.  In System 1, we are simply more susceptible to cognitive bias.  If nothing else, such a stimulus (interruption of System 1) offered via a question gives us the opportunity to engage System 2, and thus elevate our cognition upward to a higher-order, more explorative state (e.g. what can be referred to as "cognitive buoyancy").


This, then, should have us consider whether all questions have equal value in serving this purpose of stimulating explorative cognition (e.g. critical thinking).  In my opinion, of course they do not.  Certainly, open-ended questions are generally more valuable than more narrowly-defined questions.  Then again, even relevantly informed/guided questions can have significantly more value (as well as risk of introducing its own bias).  For example, consider the difference between/among the following:


(a) Could these symptoms be an expression of [disease x]?

(b) What else could these symptoms be indicating?

(c) What are three most likely causes of these symptoms, given that we know the patient has recently traveled within [geography x], is [y] years of age, and has previously experienced [z], ...etc.?


Note that question (a) allows the respondee to answer with a simple yes/no, and is less compelling of a System 2 exploration.  Question (b), while open-ended, can also invite the questionee to respond with merely the first qualified answer(s) that comes to mind.  Question (c) provides additional context, as well as the explicit request for some consideration of evaluative rationale ("most likely"), and more than just one answer.  Certainly there are many other question types available, but this is simply to make the point.


While having Do's and Don'ts lists can also be extremely valuable -- similar to the "forcing strategy" effect of checklists -- I would not put complete confidence in these, either.  Rather, I would suggest making such lists just one very important additional tool/intervention to the thinking process.  Relying completely on checklists, while quite valuable in prompting new thinking, can in and of themselves become a crutch...and thus dissuade one away from triggering his/her true, open-minded, explorative thought process.  We need to maintain a healthy portfolio of cognition resources (both innate and external), in my opinion.


These are my two cents, for now.  Either way, your post has stimulated excellent discussion here, and is much appreciated.


Be well in 2016.


Charlie Garland

Senior Fellow, HITLAB @ Columbia University Medical Center




Charlie Garland

office:  212.535.5385
mobile: 646.872.0256 


Developer of  <> The Innovation Cube (a.k.a. CubieTM - a Critical Thinking & Creative Problem-Solving Tool)

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Certified in Polarity Thinking <> TM 



Twitter:  <> @innovationator



-------- Original Message --------
Subject: [IMPROVEDX] Another look at Questions
From: robert bell 
<0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>
Date: Sat, January 02, 2016 5:51 pm

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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