FW: Diagnostic Error in Medicine Journal Club

Jason Maude jason.maude at ISABELHEALTHCARE.COM
Thu Feb 25 10:55:34 UTC 2016


This neatly pulls together several points:

  1.  The patient could also do the differential by using a symptom checker before the consultation. Makes sense as the doctors then get a written record of how the patient described their symptoms and which diagnoses they are concerned about. Also valuable as the patient is the expert on their symptoms and a very good reason not to dismiss the “worried well” as Peter suggests.
  2.  Recall the value of the differential being presented before the thinking starts: "Early diagnostic suggestions improve accuracy of GPs: a randomised controlled trial using computer-simulated patients” http://bjgp.org/content/65/630/e49
  3.  The differential doesn’t need to be exhaustive to be useful. A big part of its value is simply as a trigger to stop and think. We have heard that even stipulating an arbitrary 3 diagnoses from junior doctors in the UK when they present a patient dramatically changes behaviour. Just doing this across a health system would be a very cheap but effective measure to improve diagnosis
  4.  Very early studies we carried out showed it took an additional 2 minutes to use Isabel. With modern dx support tools the issue is not really the time to use, accuracy (both proven) or even additional inappropriate testing (never proven or even anecdotally reported) but still the inclination to use them.

Regards
Jason

Jason Maude
Founder and CEO Isabel Healthcare

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: Thursday, 25 February 2016 01:31
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] FW: Diagnostic Error in Medicine Journal Club

Two points…


  1.  I think it depends (or should depend) on the context more than on the clinician’s perspective. Certainly the implications of error (whether diagnostic or therapeutic) are very different with the smiling 4 year old with a runny nose and the 60 year old unresponsive patient with multiple diagnoses and medications and a BP of 70 palpable.
  2.  This may be a side trip, and I hope it is taken in the spirit it is meant (constructive) but words matter.  I never let residents, medical students or nurses I work with use the term ‘worried well’ to describe a patient. I think it is dismissive. If a patient is worried enough to go through telephone-tag hell to make an appointment, take time off work, perhaps arrange day care of a child, come to my office and pay a co-pay, I do not feel it is appropriate to consider them well. Their issue may not be life threatening or even serious. They often recognize that and say so: “This is probably nothing, but it’s been going on a while and my wife and I are worried about it.” I do not feel entitled to decide for my patient whether or not their worry is rational or irrational. The term ‘worried well’ carries with it a connotation of ‘you shouldn’t be here.’

Peter Elias, MD

On 2016.02.24, at 6:18 PM, Joan Von Feldt <joan.vonfeldt at GMAIL.COM<mailto:joan.vonfeldt at GMAIL.COM>> wrote:

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<mailto: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<mailto: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<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.
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From 1pm - 2pm CT


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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."




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