FW: Diagnostic Error in Medicine Journal Club

Jain, Bimal P.,M.D. BJAIN at PARTNERS.ORG
Wed Feb 24 18:18:18 UTC 2016


The important point I wish to emphasize is that the notion of a prior  probability or  of representativeness or of a pattern is derived from the frequency  of a disease in a series or group of patients. The problem arises as in Dr. Thompson's and other studies when this notion is employed as prior evidence for or against a disease in a given individual patient. This notion only represents the chance of finding a disease in a given patient when we look for it with appropriate tests and not evidence for it. It is fine to evaluate a disease with the highest prior probability first as it has the highest chance of being present. But if it is not found or does not explain findings in a patient then we need to consider other diseases to be evaluated, that is where differential diagnosis comes in. The differential diagnosis could be done at the start as is done in CPCs or could be done later in a serial manner when the first suspected disease is not found. It is important not to either not suspect or rule out a disease without testing just because its prior probability is low, as appears  have been done in above studies. As clinicians, we all have experience of finding a disease with low prior probability in a given individual patient.

Bimal Jain MD




From: Ely, John [mailto:john-ely at UIOWA.EDU]
Sent: Wednesday, February 24, 2016 10:12 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] FW: Diagnostic Error in Medicine Journal Club

I would change this slightly:  "This is what I think you have.  This is the expected course. If your illness does not follow this course, please get back to me.  But before you leave, I just want to go through a checklist of the causes of fatigue to make sure there's nothing else we need to consider.  Sort of like a pilot goes through a pre-flight checklist."

We can use the Pareto principle to avoid going through an exhaustive list:

The exhaustive list would  have 10,000 diseases.
60 % of patients in primary care would be covered by 3 diseases (obstructive sleep apnea, depression, deconditioning)
90% of patients would be covered by 10 diseases
99.99% of patients would be covered by 30 diseases, which is all I would go through.

The most common cause of diagnostic errors is the physician's failure to consider the diagnosis that eventually turns out to be correct.  Patient follow up is important, but it won't fix that problem.

John Ely, MD
Iowa City, IA



From: Hoffer, Edward P.,M.D. [mailto:EHOFFER at MGH.HARVARD.EDU]
Sent: Wednesday, February 24, 2016 5:59 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] FW: Diagnostic Error in Medicine Journal Club

Perhaps the single most important factor in avoiding diagnostic error in primary care is to engage the patient and use time. "An exhaustive list of every possible disease" is simply unrealistic in primary care settings, as has been pointed out. What IS realistic is to tell the patient: "This is what I think you have. This is the expected course. If your illness does not follow this course, please get back to me."
Ed
Edward P Hoffer MD, FACP

From: Grubenhoff, Joe [mailto:Joe.Grubenhoff at CHILDRENSCOLORADO.ORG]
Sent: Tuesday, February 23, 2016 12:46 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] FW: Diagnostic Error in Medicine Journal Club

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.

Sent from Skynet

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





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







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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==>

Physicians, healthcare professionals and researchers working in the field of diagnostic error are welcome to register for the session using the link below.

Participation is free.


When


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from  1pm - 2pm CT


Where


Free Online Webinar


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OVERVIEW OF THE WEBINAR SESSION
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?         Discussion and Questions - 30-45 minutes

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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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