Diagnostic Error in Medicine Journal Club

Tom Benzoni benzonit at GMAIL.COM
Fri Feb 26 16:35:29 UTC 2016


Actually, the ATM analogy works quite well:

If I put my ATM card into the card swiper to check in at work, the card
swiper still will not give me money nor will I be check into work not
permitted on the premises.
Expecting it to do those operations seems nutty but we have the same
expectations of the health care system.

If I go up to an ATM and throw my wallet at it, shouting my PIN (note that
all the necessary components are present and in proximity), I still won't
get cash. Yet we do this every day in the ED.

So I'd like to rephrase the question: How do we take variable inputs with
non-standard parts and be successful most of the time? Study that process
and improve it. Forget the rest; that will follow. Concentrating on the
failures is leading from behind.

tom

On Thu, Feb 25, 2016 at 8:11 AM, Elias Peter <pheski69 at gmail.com> wrote:

> We shouldn’t forget that there are two kinds of variation.
>
> When we talk about eliminating variation we generally mean eliminating
> clinician or system based inappropriate variation, exemplified starkly by
> the hip fracture repair done the same day on a Tuesday morning but delayed
> several days if it occurs on a weekend, or by the different patterns of
> test ordering or treatment recommendations by different clinicians based
> not on the clinical setting or evidence, but upon their personal pattern.
>
> If we are not careful, in our attempt to eliminate inappropriate
> variation, we will forget that:
>
>
>    1. Patients are, in fact, variable. It is not appropriate
>    standardization to treat two different patients the same because their LDL
>    is the same, without taking into account differences in global risk and
>    preferences/values.
>    2. Our evidence and algorithms are tentative, imperfect, and in need
>    of conscious and monitored variation if we want to improve them. Whenever
>    we develop a standardized algorithm, the understanding should be that this
>    is where the discussion and decision making begins, not where it ends. The
>    clinician should be allowed (I would argue, expected) to alter the
>    algorithm in individual circumstances, BUT this needs to be accompanied by
>    documentation of how and why the algorithm was modified, and a system to
>    collect and analyze outcomes to identify opportunities to improve the
>    algorithm.
>
>
> The ATM analogy is flawed. It applies to the simple and mechanical process
> of registering when one arrives for an appointment. It does not apply to
> the non-serial process of collecting a history, doing an exam, obtaining
> additional testing, integrating that information into a differential
> diagnosis, and working out a plan with the patient honoring their values
> and preferences. We haven’t built a machine that can do that yet.
>
> In fact, I think that long before we can build a machine that does all of
> what a skilled clinician does when working with a patient, health care
> administrators and managers will long since have been replaced by machines.
> (I don’t mean that as a snark.)
>
> Peter
>
>
>
>
> On 2016.02.25, at 7:33 AM, DR WILLIAM CORCORAN <
> williamcorcoran at SBCGLOBAL.NET> wrote:
>
>
> The healthcare industry is accepting the unacceptable: variation.
>
> I can put my debit card into any ATM in the U.S. and the ATM will treat me
> like the ATM in my local branch bank.
>
> But if I present myself for healthcare diagnosis, the result will vary all
> over the ball park. It will not only depend on which provider I go to, it
> will also depend on the time of day, the day of the week, etc. (I have two
> deceased family members who departed prematurely with wrong diagnoses
> involved.)
>
> What’s wrong with this picture? My diagnosis should be solely dependent on
> my health condition.
>
> “Variation is evil.” Jack Welch @ https://youtu.be/aNMULFcLuIM
>
> There needs to be an outraged uprising of the healthcare industry to drive
> a stake through the heart of this problem.
>
> If it is left to the patients and their survivors it will be taken over by
> the politicians and we won’t like the result.
>
> The end goal is 100% accurate diagnosis consistently reliable anywhere in
> the system. If it is achieved one place it can be rolled out at every
> place.
>
> Every shortfall needs good investigation.
>
> “A problem cannot be solved with the same mindset that created
> it.”-Einstein?
>
> Take care,
>
> Bill Corcoran
>
>
> William  R. Corcoran, Ph.D., P.E.
> 21 Broadleaf Circle
> Windsor, CT 06095-1634
> 860-285-8779
> William.R.Corcoran at 1959.USNA.com
> http://www.linkedin.com/in/williamcorcoranphdpe
> https://www.box.com/shared/kfxg1lt9dh
>
>
>
> On Thursday, February 25, 2016 6:45 AM, Bob Latino <
> blatino at reliability.com> wrote:
>
>
>
> Hi Bill
>
> I know Geri Amori below who found the comment below 'fascinating'.  She is
> considered a Risk Management Guru in the HC world.
>
> Why is that comment a revelation in HC when it has been commonplace in
> industry for decades?
>
> These people appear to me to be trying to tackle Diagnosis Error like it
> is a singular event.  They are not concerned with breaking it down into its
> manageable components and understanding what comprises 'Diagnosis Error'.
> They can't even define what it is and collect data accordingly to know the
> magnitude of the problem.
>
> Being a relative newbie to this group, what impressions do you have about
> how HC solves it problems and why they are so far behind industry in how to
> tackle solving complex problems?
>
> Just curious, because my time on this forum has just encouraged me to stay
> healthy and not have to use a hospital unless absolutely necessary.  They
> don't give much credence to 'outsiders' input on this forum, as they seem
> to be above that (my opinion of course).
>
> Hope all is well in sunny FL.  We had a round of tornados locally last
> night, so FL is looking really attractive these days:-)
>
> Bob
>
> *Robert J. Latino, CEO*
> Reliability Center, Inc.
> 1.800.457.0645
> blatino at reliability.com
> www.reliability.com
>
> *From:* Geri Amori [mailto:gamori at COVERYS.COM <gamori at COVERYS.COM>]
> *Sent:* Wednesday, February 24, 2016 8:59 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Diagnostic Error in Medicine Journal Club
>
> 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
> P: 617.526.0360
> C: 802.238.5652
>
> *COVERYS*
> One Financial Center
> Boston, MA 02111
> www.coverys.com
> 1.800.225.6168
>
> *From:* Tom Benzoni [mailto:benzonit at GMAIL.COM <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>
> 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
>
>
>
>
> Appfully Yours (Android
> <https://play.google.com/store/apps/details?id=com.physiciancognition.xebrapro>
>  | IOS <https://itunes.apple.com/us/app/xebra-pro/id1051676634>),
>
>
> *Cameron Powell**  |  *CEO, Physician Cognition, Inc.
>   ———————————————————————
>   (:  503 502 5030
>   -:  Cameron at PhysicianCognition.com <Cameron at physiciancognition.com>
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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
>
>
>
>
>
>
>
>
>
>
> *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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> *Free Online Webinar*
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> *OVERVIEW OF THE WEBINAR SESSION*
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> <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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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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