Another look at Questions

Peggy Zuckerman peggyzuckerman at GMAIL.COM
Sat Jan 9 19:48:39 UTC 2016


Dear Steve and others interested in this reporting topic,

Re the alleged 'harm' that knowledge of the findings might have to a
patient:   The harm or potential harm to the patient has alerady been done
by that which was found in the report.  The tumor was already there, the
anemia well-established, the rib already fractured, all of which may be
seen as the harm.  The patient actively seeking and cooperating in being
imaged or taking a test has acknowledged the potential for discovery of a
problem, and his desire to understand that. The reporting of data actively
sought cannot be harmful in itself, even if the expected finding is not
demonstrated and an "incidental finding" is shown. Why then would either
the simple data points or the more interpretative report be construed as
having harmed the patient?

As we diagnose more diseases through genetic and/or genomic analyses, we
will hear that there is no need to report to the patient those findings
which lack "actionable targets".  In effect, the physicians says that there
is evidence for the cause for your illness, but I have no medication or
treatment. Thus, I shall remain silent.

This approach is unethical at the very least.  The physician supporting
this says that the diagnosis must be withheld from the patient because
he--not all physicians--is unaware of a solution to the problem presented.
This damages the patient. With this knowledge, he may approach another
physician, whether then or at another time when that target becomes
'actionable', or provide that info to others, family members, researchers
or he may simply choose to ignore that information.  That is a decision to
be made by the patient, not the physician or the medical system.

Changes in federal law have made invalid those state laws which prohibit
patients from receiving their blood lab tests directly, which will
certainly be a precedent for assuring that all such medical data cannot be
withheld from the patient.

Giving immediate and unfettered access to the patient about his testings,
with or without the interpretation of those findings is a fundamental step
in minimizing diagnostic error.

Peggy Z

Peggy Zuckerman
www.peggyRCC.com

On Sat, Jan 9, 2016 at 10:14 AM, Stephen I. Lane <Stevelane at lane-lane.com>
wrote:

> I couldn't agree more with Peggy. As an attorney representing patients in
> medical negligence cases, a common theme to virtually all successful cases
> has been in a lack of communications. I've never understood the basis for
> the "Your doctor will tell you" response that is the rule when patients ask
> for their test results. Surely, giving the results to the patient can't
> cause any harm, and does bring another possibility for catching a bad thing
> before it becomes catastrophic. I have no illusion that all patients will
> understand their reports. But if they're placed in a position to ask
> someone to explain the results, aren't they better off?
>
> On a social note, I'd like to shout out to Lenny, whom I haven't seen in
> too long!
>
> Sent from my iPhone
>
>
> Steve
>
> Please respond to:
>
> Stephen I. Lane
> *P**artner*
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>
>
> For more information about our firm, please visit our website at
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>
> On Jan 9, 2016, at 11:36 AM, Peggy Zuckerman <peggyzuckerman at GMAIL.COM
> <peggyzuckerman at gmail.com>> wrote:
>
> I am a patient who is painfully aware of the number of radiology reports
> which reference meaningful problems not communicated to the patient, which
> automatically constitutes a misdiagnosis or error in diagnosis.  In the
> recent IOM report, the failure to communicate a diagnosis to a patient
> constitutes a misdiagnosis in itself.
>
> This situation can arise from the physician readsthe report only to affirm
> his suspected diagnosis, and with that being found or not being found,
> fails to read the entire report.  For example, suspecting a broken rib to
> explain a nagging pain, and not finding that, the physician may never read
> that there is a mass on the kidney. With the pressure to limit CTs, the
> unreported mass will likely not be imaged again for a year or more. The
> disaster that results from this error is obvious, and sadly, not uncommon
> with rarer diseases diagnosed incidentally, thanks to imaging done for
> other purposes.
>
> Whereas Dr. Berlin notes that the clinician has the patient.  If the
> radiologist could rightly fulfill his obligation to the patient, his report
> would go simultaneously to the patient.  Patients will read the entire
> report, despite the difficulty they present.  No phrase which includes
> "mass" or "lesion" will go unnoted to the patient, and as a minimum will
> open a conversation between patient and clinician.  Naturally, the current
> efforts by the radiology societies will make the reports more easily read
> will be welcome to patients and physicians alike.
>
> Rarely is it easy to measure the value of finding a tumor earlier than
> later, or of the cost of treatment given for the wrong disease. Certainly
> it is possible to determine if a patient has received a report with
> critical findings by asking the patient, even in a retrospective study.
> Patients have been 'taught' not to call the doctor's office for a simple
> blood test and to wait for a call with results, but are not taught that
> about 15% of problematic tests are not reported.  If there is a similar
> percentage as to radiology reports, this is a situation quickly corrected.
>
> Send the report to the patient directly.  "Nothing about me without me."
>
> Sincerely,
> Peggy Zuckerman
>
>
> Peggy Zuckerman
> www.peggyRCC.com
>
> On Thu, Jan 7, 2016 at 12:11 PM, Leonard Berlin <lberlin at live.com> wrote:
>
>> 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
>>
>> *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:        01/07/2016 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*
>> <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*
>> <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>>
>> To:        *IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG*
>> <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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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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