Another look at Questions

Leonard Berlin lberlin at LIVE.COM
Thu Jan 7 20:11:15 UTC 2016


As a radiologist, I'd like to comment briefly on radiologic errors, which admittedly can be problematic.  It is the job of our radiology societies  to  actively work to reduce error rates, and they are trying.  
 
But I'd like add the following: the radiologist has the images, and the clinician has the patient; establishing a diagnosis requires collaboration of both (not to mention results of lab and other tests).  If a clinician receive a radiology report that somehow doesn't make sense or fit into the clinician's pre-imaging DD, the clinician should not automatically accept the report.  Call the radiologist and say that somehow the imaging interpretation doesn't seem to fit: ask the rad to take another look at the images keeping in mind  the clinician's doubt. And/or, ask the radiologist to show it to one of his colleagues for a second opinion.   This is certainly not a solution to the overall problem of radiologic errors, but on the other hand every now and then such collaboration will mitigate an error before it harms the patient  and result in a correct diagnosis.
 
Sadly, in this day and age, radiologists don't communicate with ordering physicians as much as they did in the past, and as much as they should today.  That is unfortunate and a shame, but it is a fact.  But in the interest of the patient, there's no doubt that two (or sometimes even three) heads are better than one.
 
 
Lenny Berlin, MD, FACR
Skokie, IL
 
Date: Thu, 7 Jan 2016 08:53:37 -0800
From: Michael.H.Kanter at KP.ORG
Subject: Re: [IMPROVEDX] Another look at Questions
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

In terms of a list of Do's and Dont's this
could help.  I think the challenge will be to find Do's and Dont's
that are simple enough to describe but at the same time can meaningfully
reduce errors.    It is worth exploring though.   



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



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From:      
 robert bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>

To:      
 IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

Date:      
 01/07/2016 07:21 AM

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



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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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