Another look at Questions

Leonard Berlin lberlin at LIVE.COM
Sat Jan 9 22:13:48 UTC 2016


Absolute agree!  Correct.  Unfortunately such a movement does not have support of the majority of US radiologists.  But the day will come...eventually.
 
Lenny
 
Date: Sat, 9 Jan 2016 14:04:01 -0800
From: William.Strull at KP.ORG
Subject: Re: [IMPROVEDX] Another look at Questions
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

I whole-heartedly concur with Peggy's request
for  "Giving
immediate and unfettered access to the patient about his testings,"
 with a slight caveat of delaying release of abnormal results for
24-48 hours to allow for the physician to provide comments or interpretation.
 As a primary care physician myself, I have been doing just that since
the 1980's, initially sending hard-copy results with my comments by snail
mail, and in the past decade by releasing results with my comments through
the patient portal in the EMR on a routine basis.  I do think it important
for the clinician to provide comments and interpretation whenever possible,
along with the full report of the lab or imaging results.  In my experience,
patients appreciate comments from the physician, and have themselves often
noted abnormalities in the report for which further discussion or other
follow up was indicated and sometimes very appropriate.  And I agree
with Peggy that, even if the physician is not available to provide comments,
the full results should be released to the patient.

To paraphrase the title of a play, Whose resultsare
they anyway? 





William Strull MD

Medical Director, Quality and Patient Safety

Kaiser Permanente



The Permanente Federation, LLC

One Kaiser Plaza, 23B

Oakland, California 94612

510-271-5987 (office)

8-423-5987 (tie-line)

510-271-6642 (fax)

415-601-6013 (mobile phone)



Debra C. Costa (assistant)

debra.c.costa at kp.org

510-271-6031



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From:      
 Peggy Zuckerman <peggyzuckerman at GMAIL.COM>

To:      
 IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

Date:      
 01/09/2016 01:34 PM

Subject:    
   Re: [IMPROVEDX]
Another look at Questions








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

Partner

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230 W. Monroe  St.,  Suite 1900 

Chicago, Illinois      60606-4710 



Office:   (312)
332-1400

Facsimile: (312)
899-8003

Mobile: (847)
736-7769

stevelane at lane-lane.com



Past Member of Board of Directors and Past Chair of the Plaintiff and Consumer
Institute of the International Society of Primerus Law Firms

 

Lane & Lane, LLC, a family of trial attorneys dedicated
to protecting the rights of those who have been injured through the fault
of others. 

 

For more information about our firm, please visit our
website at www.lane-lane.com.


On Jan 9, 2016, at 11:36 AM, Peggy Zuckerman <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



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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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