Diagnostic Infrastructure

Alan Morris Alan.Morris at IMAIL.ORG
Mon Feb 8 21:10:51 UTC 2016


Thank you for this example.
Remember we are always making decisions in a risk/benefit evaluation
context.  The guidelines try to reflect the best current evidence.  The
evidence may change, as you have described.  The major question for our
population of patients is how do they get the highest probability of a
good outcome.  This is likely to come from execution consistently of
extant guidelines, although that is not guaranteed.

Alan H. Morris, M.D.
Professor of Medicine
Adjunct Prof. of Medical Informatics
University of Utah

Medical Director, Urban Central Region Pulmonary Function Laboratories
Pulmonary/Critical Care Division
Sorenson Heart & Lung Center - 6th Floor
Intermountain Medical Center
5121 South Cottonwood Street
Murray, Utah  84157-7000, USA

Office Phone: 801-507-4603 <tel:801-507-4603>
Mobile Phone: 801-718-1283 <tel:801-718-1283>






On 2/8/16, 09:22, "Tom Benzoni" <benzonit at GMAIL.COM> wrote:

>If you are to avoid systematic bias, you must include errors in
>guidelines.
>E.g., recall steroids in spinal cord injury.
>Big names: NIH, CDC put out big pronouncements. (references available)
>Then: Standard of care (Beneficial)
>Now: Standard of Non-care (Harmful)
>So it is honest to remember that inertia can also be safe practice.
>
>While we're discussing errors:
>Errors start with letting small slips pass (broken window theory.)
>I.e., ER's don't get to choose who they treat and so must master all
>fields AND they act as backups to all specialties (thus being the
>specialist's specialist.)
>However, there is much data that most patients on PPIs don't have the
>disease for which they are being treated and most antibacterial agents
>are prescribed for people with viral illnesses.
>This type of heuristic, writing a script for a treatment which is not
>needed, represents a much bigger source of diagnostic error because it
>is foundational. This is what happened in Ebola/Duncan.
>
>As I teach my residents. "It's awful hard for your patient to get
>better on your treatment for a disease which they don't have." Or,
>more crudely, you can give me (60 y.o. male) a prescription for OCP
>(oral contraceptives) and, even if I'm non-adherent, I'll still not
>get pregnant.
>
>tom benzoni
>Des Moines
>
>On Mon, Feb 8, 2016 at 8:54 AM, Jason Maude
><jason.maude at isabelhealthcare.com> wrote:
>> Mike
>> Many thanks for highlighting this story. I would love to compile a
>> compendium of similar stories such as Semmelweis and hand washing,
>>Lister
>> and antiseptics, Laennec and the stethoscope, Barry Marshall and
>>hpylori.
>> The average adoption time must be more than a generation!
>> Please let me know of any other notable ones to add to the list.
>>
>> Regards
>> Jason
>>
>> Jason Maude
>> Founder and CEO Isabel Healthcare
>> Tel: +1 703 879 1890
>> www.isabelhealthcare.com
>>
>> From: "Bruno, Michael" <mbruno at HMC.PSU.EDU>
>> Reply-To: Society to Improve Diagnosis in Medicine
>> <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, "Bruno, Michael"
>><mbruno at HMC.PSU.EDU>
>> Date: Friday, 5 February 2016 20:32
>> To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG"
>> <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>>
>> Subject: Re: [IMPROVEDX] Diagnostic Infrastructure
>>
>> I think this sort of thing has been a problem throughout history.  For
>> example, consider the classic ³history of medicine² story of Scurvy and
>> Vitamin C from the 18th Century:
>>
>>
>>
>> ³Šthe first attempt to give scientific basis for the cause of this
>>disease
>> was by a ship's surgeon in the British Royal Navy, James Lind. While at
>>sea
>> in May 1747, Lind provided some crew members with two oranges and one
>>lemon
>> per day, while others were given cider, vinegar, sulfuric acid or
>>seawater,
>> along with their normal rations. In the history of science this is
>> considered to be the first occurrence of a controlled experiment
>>comparing
>> results on two populations of a factor applied to one group only with
>>all
>> other factors the same. The results conclusively showed that citrus
>>fruits
>> prevented the disease. Lind published his work in 1753 in his Treatise
>>on
>> the Scurvy1Š
>>
>>
>>
>> But doctors, as a group, generally refused to accept Lind¹s results, and
>> most clung to out-moded and unproven ideas about Scurvy, such as the
>>idea it
>> could be prevented by drinking acid solutions.
>>
>>
>>
>> ³ŠThey considered that scurvy was a disease of internal putrefaction
>>brought
>> on by faulty digestion caused by the naval diet. Although this basic
>>idea
>> was given different emphases by successive theorists, the remedies they
>> advocated (and which the navy accepted) amounted to little more than the
>> consumption of Œfizzy drinks¹ to activate the digestive system, the most
>> extreme of which was the regular consumption of Œelixir of vitriol¹ ­
>> sulphuric acid taken with spirits and barley water and laced with
>>spices. In
>> 1764, a new variant appeared. Advocated by Dr David McBride and Sir John
>> Pringle, Surgeon General of the Army and later President of the Royal
>> Society, this idea was that scurvy was the result of a lack of Œfixed
>>air¹
>> in the tissues which could be prevented by drinking infusions of malt
>>and
>> wort whose fermentation within the body would stimulate digestion and
>> restore the missing gasesŠ²
>>
>>
>>
>> As a direct result of stubborn and wrong-headed physician intransigence,
>>
>>
>>
>> ³Šit was 1795 before the British navy adopted lemons or lime as standard
>> issue at sea.²
>>
>>
>>
>> No telling how many sailors were condemned to suffer and die horribly
>>from
>> Scurvy in the 45 year delay between 1753, when Lind¹s results were first
>> published, and 1795, when the British navy began to provision ships with
>> citrus fruits!?!  Certainly more died from scurvy than died from actual
>> combat.  45 years!!  That is even worse than our modern FDA delays the
>> dissemination of proven treatments and technologies.
>>
>>
>>
>> Have a great weekend, all!
>>
>>
>>
>> Mike
>>
>>
>>
>>
>>
>> References:
>> 
>>http://www.bbc.co.uk/history/british/empire_seapower/captaincook_scurvy_0
>>1.shtml,
>>
>>
>>
>> 
>>https://dash.harvard.edu/bitstream/handle/1/8852139/Mayberry.html?sequenc
>>e=2
>>
>>
>>
>> https://en.wikipedia.org/wiki/Scurvy
>>
>>
>>
>> and
>>
>>
>>
>> http://www.healthaliciousness.com/articles/lind-scurvy-vitamin-C.php
>>
>>
>>
>>
>>
>>
>>
>> From: Robert Bell
>> [mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG]
>> Sent: Friday, February 05, 2016 1:08 AM
>> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>> Subject: Re: [IMPROVEDX] Diagnostic Infrastructure
>>
>>
>>
>> Excellent points Peggy,
>>
>>
>>
>> The acceptance of new treatments is far too slow. I think it took about
>>10
>> years in the US  for H.  pylori to be fully acepted as a the cause of
>>peptic
>> ulceration and that antibiotics were the cure.
>>
>>
>> Rob
>> Sent from my iPad
>>
>>
>> On Feb 4, 2016, at 2:23 PM, Peggy Zuckerman <peggyzuckerman at GMAIL.COM>
>> wrote:
>>
>> How do we get the error rate down when there is such diverse range of
>>issues
>> that cause such error?  We can certainly approach those known errors in
>>a
>> linear fashion, but that will have little impact in the near term,
>>except in
>> those cases.
>>
>>
>>
>> Just as Bell has pointed out that neither doctors nor patients are
>>getting
>> the best possible information in a timely manner, that problem is not
>> limited to Wikipedia or OpenSource documents.  A great deal of focus has
>> been made on the difficulty of replicating clinical trial studies, of
>>the
>> shifts in the reported outcomes away from the initial goals of those
>> studies, and of studies which are sadly incomplete of the data which
>>would
>> give clinicians greater and more reliable guidance in treatment.  Then
>>there
>> is the issue of the acceptance of change which might derive from those
>> studies, said by some require at least 14 years for 50% of the
>>clinicians
>> incorporating even new guidelines in their practices.
>>
>>
>>
>> Rather than focusing on one topic or type of error, there must be a
>>cultural
>> change in the diagnostic process.  Part of that--and there are a myriad
>>of
>> parts--is permitting and encouraging patients to receive and read their
>> complete medical records.  Following that is the need for patients to
>> correct the errors in those records, and to be able to share them freely
>> with other family members or providers.
>>
>>
>>
>> There also needs to be a way for a misdiagnosis or concern for such to
>>be
>> reviewed by a responsible party.  The sheer number of patients who are
>> treated for something which they do not have, and at the expense in
>>time,
>> life and limb, is staggering.  However, imagine the resources to be
>>freed up
>> when they are not dispersed incorrectly and with greater long-term
>>cost.  We
>> all will benefit from approaching this as cultural shift, as
>>significant in
>> society as was the civil rights and womens' movements.
>>
>>
>>
>> Peggy
>>
>>
>>
>> This while thinking as a board member of the Society for Participatory
>> Medicine (participatorymedicine.org),as well as patient advocate.
>>
>>
>>
>>
>>
>>
>> Peggy Zuckerman
>> www.peggyRCC.com
>>
>>
>>
>> On Thu, Feb 4, 2016 at 12:36 PM, robert bell
>> <0000000296e45ec4-dmarc-request at list.improvediagnosis.org> wrote:
>>
>> To all on the list.
>>
>>
>>
>> A friend kindly sent me this:
>> 
>>http://www.brookings.edu/blogs/techtank/posts/2016/01/11-open-access-scie
>>ntific-knowledge
>>
>>
>>
>> It seems that much of the information that we see is obtained from Open
>> Access information not from closed source Scientific Journals. Wikipedia
>> editors are 47 percent more likely to use Open Source Journals for their
>> information.
>>
>>
>>
>> Consequently, the the public and probably also physicians are not
>>getting
>> the very best scientific information in a timely way.
>>
>>
>>
>> This brings up the issue of what I will call the Diagnostic Medical
>> Infrastructure.
>>
>>
>>
>> If the infrastructure is not sound, information is not being
>>distributed in
>> the best way to physicians and the public to focus on evidence based
>> medicine, physicians are missing a ³raised" PSA test when someone has
>>had a
>> prostatectomy, and a large percentage of radiologists are missing an
>>image
>> of a "Gorilla² on an X-ray, and also a thousand and one other problems,
>> particularly in the communication area, that in turn all lead to error,
>>how
>> can we hope to successfully first tackle diagnostic errors?
>>
>>
>>
>> If the current diagnostic error rate on all patients is say 30% would
>>it not
>> be better to get this figure down before focussing on improving
>>diagnoses as
>> a whole? It may be possible to tackle the standard errors and diagnostic
>> errors together in some way but surely some of the standard errors have
>>to
>> be dealt with first to save lives and injury.
>>
>>
>>
>> Triaging some of these problems, correcting/improving them, could
>>quickly
>> start reducing the current diagnostic errors.
>>
>>
>>
>> Should we first be focussing on the Diagnostic Medical Infrastructure?
>>
>>
>>
>> Should our focus first be on the best ways to save lives and stop
>>patient
>> injury?
>>
>>
>>
>> Robert M. Bell, M.D.
>>
>>
>>
>>
>>
>>
>>
>>
>>
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>> Medicine
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>> Medicine
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