Diagnostic Error in Medicine Journal Club

Tom Benzoni benzonit at GMAIL.COM
Wed Feb 24 22:49:30 UTC 2016


It would be helpful to keep in mind there is error on both sides:
If I order a CTA of the lungs to rule out a PE in low probability patient,
I've made an error.
If that CTA comes back with a maybe reading and I start anticoagulants,
I've made an error that carries risk of harm that exceeds risk of benefit.
Yet we penalize only the miss, not the incorrect (+).
tom

On Wed, Feb 24, 2016 at 2:42 PM, Charlene Weir <charlene.weir at utah.edu>
wrote:

> Iliad was developed at UU by Homer Warner and group as a diagnostic
> decision support system. The best feature, I thought, was the ability to
> offer what is the next best piece of information to gather. . .
>
>
> Charlene
>
> From: Elias Peter <pheski69 at GMAIL.COM>
> Reply-To: Society to Improve Diagnosis in Medicine <
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Elias Peter <pheski69 at GMAIL.COM>
> Date: Wednesday, February 24, 2016 at 1:17 PM
> To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> Subject: Re: [IMPROVEDX] Diagnostic Error in Medicine Journal Club
>
> Great question. I parse it this way:
>
>
>    - No normal clinician is capable on the fly of generating the
>    exhaustive list, let alone put them in order of probability.
>    - A computer might do this pretty well, but it depends on the back end
>    programming and the data entered.
>    - It still depends on someone  (not necessarily the clinician) having
>    the skill and taking the time to enter the data.
>    - It would probably decrease the number of diagnoses missed because of
>    the availability heuristic and because of lack of knowledge.
>    - It would still run the risk of increased and possibly
>    unnecessary/inappropriate testing. (“The computer suggested splenic artery
>    aneurysm as a cause of LUQ pain, so why didn’t you order imaging at that
>    visit?”) This could be minimized by setting it to provide the top 3 or top
>    5 probabilities, annotated, and give a larger list only upon request. I
>    might want to see 3-5 options for common and simple problems at the first
>    visit, but be able to expand the list if the patient has new symptoms,
>    doesn’t improved...
>
>
> A tool like this is definitely on my wish list, but I would want it field
> tested and data about NNT/NNH, impact on time, etc.
>
> Peter
>
>
>
> On 2016.02.24, at 2:53 PM, Cameron Powell <cameron at PHYSICIANCOGNITION.COM>
> wrote:
>
> Peter, would you say the same thing when the exhaustive list is produced
> automatically, either immediately upon the physician's input of relevant
> variables or even before the patient reaches the physician? If they’re in
> probabilistic order?
>
> Studies have shown that when doctors are presented with an intelligent
> list of differentials, they do make higher quality decisions.
>
> Cameron
>
>
>
>
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>
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> On Feb 23, 2016, at 6:45 PM, Elias Peter <pheski69 at GMAIL.COM
> <pheski69 at gmail.com>> wrote:
>
> I have two objections to this.
>
> The first relates to resources. From the perspective of a primary care
> physician, the “...creation of an exhaustive differential diagnosis listing
> all diseases regardless of prior probabilities in every patient…” would
> mean I make very few diagnostic errors on the two or three patients I see
> every day.
>
> Even in something as mundane as a sore throat this is not realistic: self
> limited multiple viruses, GABHS, non-group A strep, diphtheria,
> mononucleosis, Lemierre’s, GC, HIV, herpes, coxscakie, malignancy, GERD,
> sinusitis, voice abuse, dry air, foreign body. For abdominal pain…
>
> The second is that an exhaustive list of possibilities is likely to lead
> to considerable unnecessary testing and false positives with further
> testing, over diagnosis and over treatment.
>
> Peter Elias, MD
>
>
>
> On 2016.02.19, at 7:48 AM, Jain, Bimal P.,M.D. <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
>
>
>
>
>
>
>
>
>
>
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>
> *From:* Society to Improve Diagnosis in Medicine [
> mailto:info at improvediagnosis.org <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
>
>
>
> <http://r20.rs6.net/tn.jsp?f=001NXIoYwDLr83bLGFfGtb0LURm3bKmVW_jRoNgrMyFVqdy-a3tiQYyOez3PoTy7ogyS8QVY9UzE8RP_EgnjniXY_8fSaKN0tBre2IJriQE1yJa9Mfe5CcQ_NCJYIVOPKV4ZwFUutzdM0tK7i_F_MrTazX2PfvQk78aRlFoLk0FppA5-RTRGzijPw==&c=gsgqHa0vIyo2c-7PoWTxwP3mDi_ElXGpdNt2cNd-wDtsoMidc5a8aA==&ch=yOonVj2aA6Ashu-lrk3ZGxD-vHGFOIteuKNP-r9zuzMNd9y9xEmMjQ==>
> *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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> Physicians, healthcare professionals and researchers working in the field
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> *Thursday, March 3, 2016 *From 1pm - 2pm CT
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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