Fwd: [IMPROVEDX] Diagnostic Error in Medicine Journal Club

Wansaicheong Gervais Khin-Lin (TTSH) gervais_wansaicheong at TTSH.COM.SG
Sat Mar 5 06:20:36 UTC 2016

Dear Robert,

Re: blood taking with a sleeved arm

The answer is 0.76 mmHg for systolic and -0.31 mmHg for diastolic (See reference below).
Stop making assumptions – the first thing that happens in cognitive errors.
And don’t assume that the other questions raised aren’t valid – I just haven’t looked up the answers.


A comparison of blood pressure measurement over a sleeved arm versus a bare arm
Grace Ma, MD, Norman Sabin, MD, and Martin Dawes, MBBS MD
CMAJ. 2008 Feb 26; 178(5): 585–589.
doi:  10.1503/cmaj.070975
PMCID: PMC2244664

From: Robert Bell [mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG]
Sent: Sunday, 28 February 2016 1:12 PM
Subject: [IMPROVEDX] Fwd: [IMPROVEDX] Diagnostic Error in Medicine Journal Club

Sent from my iPad

Begin forwarded message:
From: robert bell <rmsbell200 at yahoo.com<mailto:rmsbell200 at yahoo.com>>
Date: February 27, 2016 4:57:56 PM MST
To: Art Papier <apapier at VISUALDX.COM<mailto:apapier at VISUALDX.COM>>
Subject: Re: [IMPROVEDX] Diagnostic Error in Medicine Journal Club
Art, Nice response.

I think there is so much we do not know - perhaps where we should start.

"Diagnostic things at our disposal" (or the diagnostic infrastructure - to get from A to B we need a few bridges, tunnels, and maybe ferries). Stethoscope, fingers, tongue blade, communication (language barriers), variation in presentation, completeness of history and physical, etc. etc. all become part of the standard work up. - Labs, EKG, or imaging would add to the error load). All of these have differing errors in different hands. Do we know what these are? Should we know?

We do not know the error rate on all of them, do we even know if one is more important than the other.  Do we know the percentage of patients seen by differing physicians who are just history and physical patients (no labs, EKG, or imaging)?

I would have thought that the stethoscope in different hands had the greatest error - but could be wrong.

I would also think that most/many physicians had high frequency hearing impairment (particularly the young with loud music exposure). I am not sure what effect that has on diagnosis but presumably adds to the error rate - should we know? If hearing loss is significant should those HCPs use stethoscopes?!

We do not know what is the overall level of handicapped physicians (with impaired physicians - drugs, alcohol, emotional there are probably figures from the State Medical Councils) - the handicap could be in many different areas. Pilots have pretty strict physical exams. Should Physicians? Should we know?

Speed is a big problem and I suspect related to the Burn Out Rate. And it must also impact accurate diagnoses.

Here is the link to the AMA report by specialty. http://www.ama-assn.org/ama/ama-wire/post/specialties-highest-burnout-rates

Thanks for your comments on Simulation, CDS, EHR, and I will throw in telemedicine - all so valuable. How can we to get some of these thoughts researched and if working introduced so we can start making changes and saving a few lives?

But there is so much error in the history and physical with and without labs or imaging that it is foolhardy to focus on diagnostic errors alone. The infrastructure really needs repairing.

Whenever I see a PCP or Specialist, Nurse Practitioner, or Physician’s assistant, approximately 80% listen to my chest and heart through my shirt. What is that doing to accuracy? Do we know? Similarly a BP measurement through clothing (are there studies there that tell us the error in mm of Hg?). How accurate is taking the BP in a non-approved way?

Let’s start with the basics. Which brings up the thought, WHAT IS OUR MISSION AND WHAT ARE OUR SPECIFIC GOALS TO GET THERE?

Thanks Art,


(removed for brevity)



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