FW: Diagnostic Error in Medicine Journal Club

Joan Von Feldt joan.vonfeldt at GMAIL.COM
Wed Feb 24 23:18:02 UTC 2016


HI Tom
I guess it depends on your perspective.
Most of your patients may be the worried well.
However, some of us take care of patients and medical conditions that if
there is a misdiagnosis, or delay to diagnosis, poor outcomes can result.



Joan M. Von Feldt, MD, MSEd
Professor of Medicine
Division of Rheumatology
University of Pennsylvania
Clinical office: 215-662-2454
Cell: 215-900-5659
Or 267-283-5828
*"Learning is like rowing upstream; not to advance is to drop back."*


On Wed, Feb 24, 2016 at 10:08 AM, Tom Benzoni <benzonit at gmail.com> wrote:

> Interesting conversation; reminds me of the query:
>
> What do you know about a well patient?
> They haven't been worked up enough yet!
>
> I think we over-inflate our importance.
> Admittedly, that's necessary to do our work, but among ourselves we can
> confess that we are mostly irrelevant to our patients complaints.
> It is this first sort that we must execute perfectly.
>
> The art of medicine consists in amusing the patient while nature cures the
> disease.
>
> Voltaire <http://www.brainyquote.com/quotes/authors/v/voltaire.html>
>
>
> On Wed, Feb 24, 2016 at 5:58 AM, Hoffer, Edward P.,M.D. <
> EHOFFER at mgh.harvard.edu> wrote:
>
>> 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
>> *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
>> <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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>>
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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==>
>>
>>
>> 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*
>>
>>
>>
>>
>> *Thursday, March 3, 2016 *From 1pm - 2pm CT
>>
>>
>>
>> *Where*
>>
>>
>>
>> *Free Online Webinar*
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>>
>> * Register Here!
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>>
>>
>>
>>
>>
>>
>>
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-- 

Joan M. Von Feldt, MD, MSEd
Professor of Medicine
Division of Rheumatology
University of Pennsylvania
Clinical office: 215-662-2454
Cell: 215-900-5659
Or 267-283-5828
*"Learning is like rowing upstream; not to advance is to drop back."*






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


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