FW: Diagnostic Error in Medicine Journal Club

Grubenhoff, Joe Joe.Grubenhoff at CHILDRENSCOLORADO.ORG
Tue Feb 23 17:46:10 UTC 2016

One must consider the relative cost of generating an "exhaustive differential" for each patient's presentation in time or resource constrained practice settings. The high volume primary care office or ED survives on pattern recognition to optimize efficiency. Additional lab tests, perseveration on more rare diseases may unintentionally increase DxE by going down rabbit holes or chasing false positives or increasing decision fatigue.These cognitive dispositions are resilient because they often function to the diagnostician's and patient's benefit. I agree that asking the question, "Does all the data fit the working dx?" is important but requires balance between being conscientious about our diagnostic reasoning and avoiding the overthinking that prevents us from seeing the forest for the trees.

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On Feb 23, 2016, at 10:19, Jain, Bimal P.,M.D. <BJAIN at PARTNERS.ORG<mailto:BJAIN at partners.org>> wrote:

As I shall not be able to attend the DEM Journal Club on Thursday, March 3, I present here my thoughts on Dr. Thompson’s important paper on diagnostic errors in primary care.

1.       The main reason for failure to suspect a disease when its presentation was atypical was ,as Dr. Thompson points out, reliance on pattern recognition.

2.       Reliance on pattern recognition is, I believe, a cognitive bias similar to or the same as representativeness in which a disease with atypical features is not suspected(Ely, Graber, Croskerry Acad. Med. 86: 2011, 307-313).

3.       In pattern recognition as well as in representativeness, the typicality of a presentation or frequency of a disease given a presentation is considered evidence for or against that disease in a given, individual patient.

4.       Thus the low frequency or low prior probability of a disease in a patient with atypical presentation is considered prior evidence against that disease which may then not be suspected.

5.       We note that a probabilistic approach to diagnosis in which prior probability represents prior evidence may actually promote failure to suspect a disease in patient with atypical presentation.

6.       This diagnostic error has also been reported by H. Singh et al( JAMA Intern Med Published online Feb 25 2013 48-25) and John Ely et al (JABFM 25: 2012 87-97)

7.       The best way to eliminate this diagnostic error is to understand that atypicality of a presentation or low prior probability of a disease is not evidence against it in a given, individual patient.

8.       The creation of an exhaustive differential diagnosis listing all diseases regardless of prior probabilities in every patient as is done in CPCs in NEJM and then evaluating each disease in it by its ability to explain patient findings would go a long way in reducing or eliminating this diagnostic error.

9.       With this approach one hundred diagnostic accuracy was achieved in 50 CPCs that I reviewed recently.


Bimal P Jain MD

Pulmonary-Critical Care

Northshore Medical Center

Lynn MA 01904

From: Society to Improve Diagnosis in Medicine [mailto:info at improvediagnosis.org]
Sent: Wednesday, February 17, 2016 6:05 PM
To: Jain, Bimal P.,M.D.
Subject: Diagnostic Error in Medicine Journal Club


Presents the First 2016

Diagnostic Error in Medicine
Journal Club

The Journal Club sessions focus on a publication of interest in the diagnostic error field and provide an opportunity for the participants to engage in research-related interactive discussions. The goal of the Journal Club is to generate novel discussions on scholarship and academic advancement, brainstorm ideas for new research methodologies and projects, and facilitate collaboration among new researchers in the field of diagnostic error.

In this upcoming session, Dr. Matthew J. Thompson will discuss his recent publication: Goyder CR, Jones CHD, Heneghan CJ & Thompson MJ.  Missed opportunities for diagnosis: lessons learned from diagnostic errors in primary care. BR J  Gen Pract. 2015 1;65 (641) :e838-44.

Accessible at http;//bjgp.org/content/65/641/e838.long<http://r20.rs6.net/tn.jsp?f=001NXIoYwDLr83bLGFfGtb0LURm3bKmVW_jRoNgrMyFVqdy-a3tiQYyOYLunYmWPsic0OduilTzPf_fhHnr60XrkRGEpXElm8G-0t7slabepsDnaEm4ADwwqcZ_5a8KuEn2x6mmQop-q1tcHlBColHWy0XW5Wl-GsZstheaIJnkPWWAoI36GaQ19VFNDMZTT0BxZ9sVuvcKi4w=&c=gsgqHa0vIyo2c-7PoWTxwP3mDi_ElXGpdNt2cNd-wDtsoMidc5a8aA==&ch=yOonVj2aA6Ashu-lrk3ZGxD-vHGFOIteuKNP-r9zuzMNd9y9xEmMjQ==>

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  *   Overview of the Article - 10-15 minutes
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