Another look at Questions

Michael.H.Kanter at KP.ORG Michael.H.Kanter at KP.ORG
Sun Jan 10 18:26:02 UTC 2016


This is really complicated issue in my view.  Some of my thoughts.
1) all results should be given to patients based on ethical grounds. 
Sadly, this does not happen consistently.  In terms of reducing diagnostic 
errors informing patients of all results likely will help prevent some 
labs from get overlooked.  Having said this,  in our most recent study on 
abnormal creatinine values not getting acted on, many not acted on had the 
 results given to the patients via our patient portal and yet they were 
still not acted on.  Our study was not designed to test whether patients 
using our portal that sends them virtually all lab results decreased the 
rate of failure to act on labs but I can state, that even when patients 
are given the abnormal results, a sizable number still do not get acted 
upon.  So informing patients of test results is the right thing to do but 
likely wont prevent all errors in not following up abnormals.
2)  there is harm that can occur when patients are informed of abnormal 
tests in the form of unnecessary stress or concern over the implications.. 
 This potential harm needs to be considered PRIOR to the physician 
ordering the test though.  An example may be lung cancer screening where 
if one orders a CT to screen for lung cancer, there is a significant risk 
of finding an incidentaloma that may requiring follow up and create a 
great deal of patient anxiety.  This does not mean one never order a CT 
scan to screen for lung cancer in appropriate patients but on that  the 
potential psychological harms are concidered as part of the risk/benefit 
prior to ordering the test.   Once it is ordered, results need to be given 
to the patient. 

Michael Kanter, M.D., CPPS
Regional Medical Director of Quality & Clinical Analysis
Southern California Permanente Medical Group
(626) 405-5722 (tie line 8+335)
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From:   robert bell 
<0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>
To:     IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Date:   01/09/2016 10:23 PM
Subject:        Re: [IMPROVEDX] Another look at Questions



Thanks Dr. Strull,

Does anyone know how frequently lack of call back/communication with the 
patient occurs in ambulatory practice for both positive and negative test 
results? I understand that it is not uncommon to call back only positive 
results - is that appropriate?. 

If the figures are relatively high it would seem not to warrant any 
restriction on the patient knowing immediately the results are available.

Rob Bell, MD
On Jan 9, 2016, at 3:04 PM, William Strull <William.Strull at KP.ORG> wrote:

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
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Mobile: (847) 736-7769
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Past Member of Board of Directors and Past Chair of the Plaintiff and 
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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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