Diagnostic Error in Medicine Journal Club

Geri Amori gamori at COVERYS.COM
Thu Feb 25 01:58:36 UTC 2016


This is a fascinating comment.  We have always penalized the “miss” and  not penalized when the incorrect or work-around process has not harmed.  This has been a long noted concern for  Just Culture and in Patient Safety science.  For example, when people have engaged in work-arounds that did not harm the patient, we ignored them.  Sometimes we even praised the folks who managed to “save” the day.  But if a patient happens to be harmed by the same work around we punish or fire the protagonist and call them names like “negligent” often for the very same behavior.  It’s the same phenomena in diagnostic error:   We order something looking for the zebra, we are over-testing;  we decide not to test but to treat based on probability, we are over-treating;  we decide not to test and not to treat and we are negligent.  Where is the balance?

It may well be that there IS no balance and that we as a society and a field decide which of the “evils” is better for patients….Is it better not to test or treat and risk missing some diagnosis?  In a culture of autonomy that will not be easily accepted by the courts or by patients themselves.  Is it better to risk over diagnosis through extensive testing.  Literature has shown that patients feel better knowing they have been tested, but what does that do to payer issues….and what about those patient who undergo unnecessary treatment because of a chance finding that perhaps didn’t need to be treated.  That leads to over treatment…another conundrum.

What is better for patients?  What is healthiest for providers and the system?  How do we decide?

I think it’s up to those of us who care about this issue to propose what the guidelines should be.

Geri Amori, PhD, ARM, CPHRM, DFASHRM
Vice President, Academic Affairs
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From: Tom Benzoni [mailto:benzonit at GMAIL.COM]
Sent: Wednesday, February 24, 2016 5:50 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Diagnostic Error in Medicine Journal Club

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<mailto: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<mailto:pheski69 at GMAIL.COM>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Elias Peter <pheski69 at GMAIL.COM<mailto:pheski69 at GMAIL.COM>>
Date: Wednesday, February 24, 2016 at 1:17 PM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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<mailto: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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On Feb 23, 2016, at 6:45 PM, Elias Peter <pheski69 at GMAIL.COM<mailto: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<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.
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