FW: Diagnostic Error in Medicine Journal Club

Wansaicheong Gervais Khin-Lin (TTSH) gervais_wansaicheong at TTSH.COM.SG
Sat Mar 5 06:29:37 UTC 2016


Dear Ruth,

Have you tried to sell an automatic car to a man who wants a manual stick shift?
The giving up of rights is an emotional response, not a logical one.

I agree that CDS can work but getting people to see that is more than just telling.
Healthcare workers are remarkably like patients – they need time, patience and kindness as they grow and adapt.

Gervais

From: Ruth Ryan [mailto:ruthryan at COX.NET]
Sent: Monday, 29 February 2016 5:36 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: [IMPROVEDX] FW: Diagnostic Error in Medicine Journal Club

Art,

Eloquently put. Especially about EHR as 747 without instruments.

We may all be driving driverless cars before EHR is fixed.  We may miss the driving experience, and our decades of driving skills may go to waste.

Not so with diagnostic CDS. Clinicians are not giving up their driving or flying rights, or mastery of the art of medicine; the skills of expert and novice diagnosticians alike are only enhanced with the aid of diagnostic CDS.

Ruth

Ruth Ryan RN, BSN, MSW, CPHRM
Medical writer
Risk management/patient safety
Continuing medical education
Telephone (504) 256-8797
Email ruthryan at cox.net<mailto:ruthryan at cox.net>
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From: Art Papier [mailto:apapier at VISUALDX.COM]
Sent: Saturday, February 27, 2016 4:17 PM
Subject: Re: Diagnostic Error in Medicine Journal Club

Robert,
I am not sure what you mean by “diagnostic things at our disposal”    I assume you mean lab tests and diagnostic imaging.

For the sake of this conversation, let’s consider diagnostic error around diagnoses that are made from history and physical, that are clinical diagnoses with no labs or imaging.    Let’s consider a primary care physician, PA or NP practicing in a rural county say 100 miles from a specialist with no telemedicine available.  Let’s assume they have reasonable hearing and are not color blind and have no handicaps, in other words, most clinicians.

“And how do you know you have not had the training, or have significant hearing loss at different frequencies?”
Admittedly this is a concern, but Is this really the major problem in diagnostic errors?.  Handicapped physicians?   Cognitive mistakes appear to related to the necessary heuristics of operating in an environment requiring speed and rewarding speed over quality and thoroughness.  Generalists such as EM physicians and FM and Primary care memorize and focus on the common and the serious for good reason.  No one can memorize it all, no one can be an expert across all specialties.  But your patient expects you to be an expert.  A fundamental question is if we can relieve some of the memorization burden and train in information instruments to extend our minds.  Clinicians need training in how to optimize information for the decision making moment.  Many embrace point of care technology, many do not.  Is there an ideal way to practice? Practice with information intensity at the point of care?..... or for the next 10, 20 or 30 years will we continue a paradigm of adhoc problem solving and model for our medical students unaided decision-making?  We believe medical training will evolve to reward information use at the point of care.   We have evidence from our database server that the transition is well underway.  (over 100 million viewed images in 2015, thousands and thousands of diagnostic searches, medication induced disease searches, etc.   So this is not the future it is now )

“Are there technological supports to improve things?”.  Answer:  Yes

“And is the variation seen added to with different patients from around the world?” Yes
We model the prevalence of disease by country, we also allow the user to visualize skin findings by skin type, if the patient is a person with a dark skin color, the user can view how the disease appears in a person of similar color.

“Could we use simulation training?”  You can and should use simulation for procedures and for training in emergencies, but we should not believe we can simulate and load the brain for all of diagnostic reasoning in medicine.  Diagnostic reasoning should involve CDS.   The point of clinical decision support is to create guidance systems that are an aide to cognition.  In our work we are focused on designing the ultimate guidance system which includes guiding the questions you should ask the patient.

We believe in problem-oriented design.  To be clear, CDS does not equal putting a book on line.  This is customizing knowledge to fit the unique patient scenario and information need of solving the problem at hand.

You would never expect your pilot to memorize the route and fly with no instruments.  Yet some doctors practice like such a pilot.  We are focused on purposely designing the instruments of the medical cockpit. Buying an EHR today is like buying a 747 with no navigational instrumentation.  Doctors rightly see the EHR today as a documentation/billing vehicle.  What should the EHR really be?  We need to reinvision “Medical Records That Guide and Teach<http://www.nejm.org/doi/full/10.1056/NEJM196803142781105>”  with CDS that transforms the electronic record to a thinking aide.  I am an optimist.  This transformation is underway.

Best
Art



From: Robert Bell [mailto:rmsbell200 at yahoo.com]
Sent: Saturday, February 27, 2016 10:12 AM
To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>; Art Papier <apapier at VISUALDX.COM<mailto:apapier at VISUALDX.COM>>
Cc: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Diagnostic Error in Medicine Journal Club

Great post Art.

But right now with the dignostic things at our disposal are there some symptoms/presentations that should not be dignosed by those without the training?

A little like using a stethoscope with a hearing deficit?

And how do you know you have not had the training, or have significant hearing loss at different frequencies?

And is the variation seen added to with different patients from around the world?

As you say a lot of pressure on the primary care physician. No wonder with too great a volume of patients there is burn out.

Are there technological supports to improve things?

Could we triage out the more serious things? And we do that to some extent, but we still miss PE.

Could we use simulation training? would that help? But it seem that we should ybe doing something different.

Rob Bell



Sent from my iPad

On Feb 25, 2016, at 9:02 AM, Art Papier <apapier at VISUALDX.COM<mailto:apapier at VISUALDX.COM>> wrote:
Variation in presentation is a great thread and topic for this listserv.   In dermatology, variation is much more obvious than in perhaps other specialties.  We take our first year residents and train their eye to recognize variants.  By the time they finish their residencies the best ones can see scabies presenting 10 different typical ways.  Experience and feedback loops cements for these residents the variation.   The variants actually are common and become typical for the expert.   But this is by no means easy or expecting from physicians, NP’s or PA’s that have to deal with any patient complain across medicine.  The diagnostic error that we often see coming from primary care or the ED almost always is an unrecognized variant.  Herpes on the palm.  Zoster presenting with large nodules. Etc.   In considering the list of most common diagnoses to involve liability, myocardial infarction, stroke, PE, Cancer of all kinds…I doubt the misdiagnosis occurred because a physician missed a typical presentation.  One of the many points that Larry Weed started making over 40 years ago was that the human mind just cannot remember all this variation, particularly across all specialties and also the questions to ask.  So medical students are typically lectured and instructed with prototypical “classic cases” and expected to generalize their thinking to variant presentations in the real world once they are in practice.  It is a flawed premise. Particularly when generalists might see a different patient every 20 minutes.   Databases, search and interface technology has been developed by us to provide the clinician with tools they use in real time to visualize variation, and to be able to compare patterns of symptoms, signs etc.  Though we started with skin, eye, oral we started thinking about the visualization of the complexity of internal disease.  We spend our time thinking about how to profile diseases to represent the variant presentations so that an end user for instance can recognize not just the patient that presents with left arm pain, chest pain, and diaphoresis as MI, but can also recognize a 60 year old with a toothache and fatigue as having an MI.  Prior efforts in diagnostic clinical decision support have reminded clinicians with a list of diseases, many very rare.  A key problem is we need to build into our systems the variation of common and known, not just reminders about the rare diseases.
Best
Art
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Art Papier MD
CEO
phone 585-272-2630
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address 339 East Ave, Suite 410 Rochester, NY 14604
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From: Elias Peter [mailto:pheski69 at GMAIL.COM]
Sent: Thursday, February 25, 2016 9:12 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Diagnostic Error in Medicine Journal Club

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<mailto: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<mailto: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<mailto: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<mailto:blatino at reliability.com>
www.reliability.com<http://www.reliability.com>

From: Geri Amori [mailto:gamori at COVERYS.COM]
Sent: Wednesday, February 24, 2016 8:59 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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<http://www.coverys.com/>
1.800.225.6168

From: Tom Benzoni [mailto:benzonit at GMAIL.COM]
Sent: Wednesday, February 24, 2016 5:50 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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




Appfully Yours (Android<https://play.google.com/store/apps/details?id=com.physiciancognition.xebrapro> | IOS<https://itunes.apple.com/us/app/xebra-pro/id1051676634>),


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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.
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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OVERVIEW OF THE WEBINAR SESSION

  *   Overview of the Article - 10-15 minutes
  *   Discussion and Questions - 30-45 minutes
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