Another look at Questions

Tom Benzoni benzonit at GMAIL.COM
Sun Mar 6 18:26:09 UTC 2016


1980-2 I rotated with radiology.
I was taught to read my own films.
The rads wouldn't give us rad info without clinical info.
I still remember him saying "This is not a game. I'm a clinician. You use a
stethoscope, I use an X Ray. We're both here with the same aim, to help the
patient. You wouldn't send the patient to cardiology without telling them
what the question is. Then don't do differently here."
I don't think there was a loss of productivity with these rounds; there is
an efficiency in direct communication.
There is a clear literature base in the assertion that readings improve
with receipt of clinical information.

tom benzoni
AOBEM, FACEP

On Sun, Mar 6, 2016 at 9:35 AM, Elias Peter <pheski69 at gmail.com> wrote:

> I would echo that.
>
> In medical school (early 1970s, University of Rochester, NY) it was
> standard to make rounds that included the radiology department where
> medical students, residents, fellows and attendings would review the films
> and discuss the case with the radiologists. These were real-time mini-CPCs
> and very useful.
>
> In residency, a radiologist (usually Dr. John Juhl) came to our FP
> residency clinic once a week with the films that had been done on our
> out-patients during the prior week. We reviewed those films with him, our
> fellow residents, and the clinical faculty and discussed both the
> radiologic and clinical aspects of the cases.
>
> Collaborative learning.
>
> Peter Elias, MD
>
> On 2016.03.06, at 9:58 AM, Koppel, Ross J <rkoppel at SAS.UPENN.EDU> wrote:
>
> Bob Wachter says the time with the radiologist's was one of the best and
> the most informative of his medical school experience.
>
>
> Ross Koppel, PhD, FACMI
>
> UNIVERSITY OF PENNSYLVANIA
>
> Sociology Dept;  LDI Senior Fellow, Wharton; &
>
> Affil Fac. Sch. of Medicine.  Chair, AMIA Clinical Information Systems
> Working Group.  Ph: 215 576 8221; Cell 215 518 0134
>
>
>
>
> ------------------------------
> *From:* HM Epstein <hmepstein at GMAIL.COM>
> *Sent:* Saturday, March 5, 2016 7:48 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Another look at Questions
>
> Hi Alan:
> What were the Dean of Yale Medical School's objections when you approached
> him? What about other medical schools in the US? Does anyone understand  -
> or can you enumerate - the reasons for the resistance to improving the
> curriculum?
> Best,
> Helene
>
>
> *--  *
> *hmepstein.com <http://hmepstein.com/> *
> <http://hmepstein.com/>
> H.M. Epstein - Writing Portfolio :: Bio <http://hmepstein.com/>
> hmepstein.com
> Bio. H.M. Epstein writes about parenting issues, politics and policy,
> physical and emotional healthcare, and passions both personal and
> professional.
>
> *@hmepstein*
> *Mobile: 914-522-2116 <914-522-2116>*
>
> *Sent from my iPhone*
>
>
>
> On Mar 5, 2016, at 8:14 AM, Alan Morris <Alan.Morris at IMAIL.ORG
> <Alan.Morris at imail.org>> wrote:
>
> We, in the past, made daily (or more frequent) rounds with the
> radiologist.  We interpreted the images together.  I also attended post
> mortem examinations, and sometimes did dissection myself.
> We had much more time for thought and scholarly activities than is now
> allowed by the “business” of medicine.
> I was not able to convince the Dean of Yale Medical School to consider
> decision-support strategies to complement clinician cognitive limitations,
> when I attended my 50th Yale reunion.
> Best wishes.
> Alan H. Morris, M.D.
> Professor of Medicine
> Adjunct Prof. of Medical Informatics
> University of Utah
>
> Medical Director, Urban Central Region Pulmonary Function Laboratories
> Pulmonary/Critical Care Division
> Sorenson Heart & Lung Center - 6th Floor
> Intermountain Medical Center
> 5121 South Cottonwood Street
> Murray, Utah  84157-7000, USA
>
> Office Phone: 801-507-4603
> Mobile Phone: 801-718-1283
>
>
> From: "Sanders, Lisa" <lisa.sanders at YALE.EDU>
> Reply-To: Society to Improve Diagnosis in Medicine <
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, "Sanders, Lisa" <
> lisa.sanders at YALE.EDU>
> Date: Saturday, January 9, 2016 at 11:21
> To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> Subject: Re: [IMPROVEDX] Another look at Questions
>
> Lenny,
> I too lament the loss of collaboration between the internist or doctors of
> any stripe who is caring for the patient and the radiologist. In my most
> recent blog post:
> http://well.blogs.nytimes.com/2016/01/07/diagnosis-lisa-sanders-pain-tinnitus-ringing-in-the-ears/
> the patient went to three doctors who could not tell him what was wrong,
> despite the fact that he had the right tests ordered and that the
> radiologist had listed the diagnosis on his very short differential. It was
> an unusual disorder and he was an unusual subject so I can imagine that it
> was easy to discount such a diagnosis. But would you trust yourself to make
> a different diagnosis without at least consulting your own favorite
> radiologist? The last physician not only did not recognize the disorder
> demonstrated by the CTA but told the patient not to worry about it and to
> come back in a year to follow up. Fortunately he didn’t do that and got the
> intervention that was needed.
>
>
> Why don’t we talk to the radiologists anymore?  Paying for that time – as
> suggested in the NAM report - might make a difference. I certainly hope so.
>
>
> Lisa Sanders M.D.
> Associate Professor
> Yale School of Medicine
>
>
> Clinician Educator
> Yale Internal Medicine Primary Care Residency
> Yale New Haven Hospital, St. Raphael’s Campus
> 1250 Chapel St.
> New Haven, CT 06511
> Office: 203-867-8117
>
>
>
>
>
>
> *From:* Leonard Berlin [mailto:lberlin at LIVE.COM <lberlin at LIVE.COM>]
> *Sent:* Thursday, January 07, 2016 3:11 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Another look at Questions
>
>
> As a radiologist, I'd like to comment briefly on radiologic errors, which
> admittedly can be problematic.  It is the job of our radiology societies
> to  actively work to reduce error rates, and they are trying.
>
> But I'd like add the following: the radiologist has the images, and the
> clinician has the patient; establishing a diagnosis requires collaboration
> of both (not to mention results of lab and other tests).  If a clinician
> receive a radiology report that somehow doesn't make sense or fit into the
> clinician's pre-imaging DD, the clinician should not automatically accept
> the report.  Call the radiologist and say that somehow the
> imaging interpretation doesn't seem to fit: ask the rad to take another
> look at the images keeping in mind  the clinician's doubt. And/or, ask the
> radiologist to show it to one of his colleagues for a second opinion.
> This is certainly not a solution to the overall problem of radiologic
> errors, but on the other hand every now and then such collaboration will
> mitigate an error before it harms the patient  and result in a correct
> diagnosis.
>
> Sadly, in this day and age, radiologists don't communicate with ordering
> physicians as much as they did in the past, and as much as they should
> today.  That is unfortunate and a shame, but it is a fact.  But in the
> interest of the patient, there's no doubt that two (or sometimes even
> three) heads are better than one.
>
>
> Lenny Berlin, MD, FACR
> Skokie, IL
>
> ------------------------------
> Date: Thu, 7 Jan 2016 08:53:37 -0800
> From: Michael.H.Kanter at KP.ORG
> Subject: Re: [IMPROVEDX] Another look at Questions
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>
> In terms of a list of Do's and Dont's this could help.  I think the
> challenge will be to find Do's and Dont's that are simple enough to
> describe but at the same time can meaningfully reduce errors.    It is
> worth exploring though.
>
> Michael Kanter, M.D., CPPS
> Regional Medical Director of Quality & Clinical Analysis
> Southern California Permanente Medical Group
> (626) 405-5722 (tie line 8+335)
> THRIVE By Getting Regular Exercise
>
> *NOTICE TO RECIPIENT:*  If you are not the intended recipient of this
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>  Thank you.
>
>
>
>
> From:        robert bell <
> 0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>
> To:        IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Date:        01/07/2016 07:21 AM
> Subject:        Re: [IMPROVEDX] Another look at Questions
> ------------------------------
>
>
>
> Dear Michael,
>
> Some good points.
>
> One of my thoughts is that we have the cart before the horse in first
> focussing on Errors in Diagnosis when something like 60% of errors are run
> of the mill standard errors. These such as communication problems that are
> associated with simple things like orders, wrong medications, computer
> problems, fatigue, education lack, and language problems. If we are truly
> interested in reducing the death toll and morbidity of Errors in Medicine
> as a whole should we not go for the jugular, identify the biggest problems,
> and tackle these collaboratively so that we get a significant reduction in
> the figures.
>
> And that brings up a big issue that first we need to have figures to be
> able to say if we are making progress. And think of the revolution that
> will create when we get into litigation and confidentiality discussions.
> That big question seems to be, can we do anything meaningful in either
> Standard and Diagnostic Errors without good data?
>
> I take your point that a large percentage of lab and x-ray reporting is
> related to diagnosis, but it is also related to monitoring over time -
> INRs, mammograms, and bone density come to mind. I do not know the
> monitoring percentage but would guess it is 10 - 20% of the total.  As
> these two specialty areas are so important to the whole of medicine it
> would seem that the consortium of specialty societies (that incidentally
> should have patient representation) could triage the main problems in these
> areas and collaboratively work on improving them. From what I hear the
> electronic patient record would be something that should be looked at
> immediately. If you do not look after the important basic foundations of
> medicine and the standard 60% of all errors that accounts for the biggest
> mortality I believe that you are never going to effectively make inroads
> into the Diagnostic Error piece of the pie.
>
> I am sure that with the benefits of technology there are many
> opportunities to reduce/improve the number of errors in both Radiology and
> Laboratory pathology.  And yes, you are correct radiology is likely to help
> make accurate diagnoses sooner than an impression made with a stethoscope
> (incidentally I have often wondered how accurate, in certain hands, the
> stethoscope is and have questioned what is its contribution to errors -
> perhaps it should be triaged close to the top!). But the technological
> advances in radiology would place it in the forefront for improvement of
> error rates.
>
> So this does not mean that we should *not* be focussing on Diagnostic
> Errors as we move forward, but strongly believe we should *first* be
> making sure that the main foundations to diagnosis are as solid as they can
> be.
>
> Yes, specialists with telemedicine links to help in the review process
> would be a wonderful idea to help with error rates.  And also a wonderful
> teaching tool to both specialist and radiologist. Could well be tried out
> with a small study if it is not already being done.
>
> One of my thoughts is that in medicine that is structured hierarchically
> we may not be asking enough questions. Particularly as technology and
> collaboration is slowly eroding that hierarchy. Questions are often less
> intrusive and more than anything are creative in group settings. Questions
> should be encouraged in all meetings if we wish to make quick progress.
>
> Do you think that Do and Don’t lists are of value?
>
> Thank you Michael,
>
> Rob Bell
>
>
> On Jan 6, 2016, at 4:54 PM, Michael.H.Kanter at KP.ORG wrote:
>
> interesting thoughts that you wrote below that are very thought provoking
> as usual.  Maybe I misunderstood but  you make the statement that " I
> felt that if there is a significant error rate in radiology reports and
> laboratory tests that this should be addressed first."
> I personally consider error rates in radiology reports and lab tests
> within the scope of diagnostic errors and not sure why we would not address
> this quickly.   I do not believe that anywhere in the IOM report did they
> suggest otherwise.    In fact, radiology report errors really fall into the
> class of diagnostic errors related to visual errors and also occur in
> pathology reports and other areas of diagnosis where the diagnosis is made
> by visual interpretation of an image.  We recently published a method on
> how to decrease these for interpretation of retinal photos
> Visual errors that are based on stored images (as opposed to looking at a
> skin lesion of a patient) have some advantages in terms of study and
> performance improvement including
> 1) they are often stored in data systems for easy retrieval and
> identification
> 2)  they can be retrospectively reviewed
> 3)  one can determine the incidence of diagnosing a disease if the image
> or image results are stored in a data system and use the variation in
> diagnosis as a measure of diagnostic error/variability as was done in the
> attached paper.
> 4)  Diagnosis based on visual images can be more easily studied because
>  the variable of data acquisition can be controlled better (that is
> everyone can look at the same image/data) which is very different than a
> physical exam or patient history.
>
> My point is that it may be simpler to study errors due to visual
> interpretation of images than other types of diagnostic errors and this is
> something to consider addressing sooner rather than later.
>
> I really like the idea of specialists societies getting involved in
> diagnostic errors.    Specialists  are likely to see such errors in their
> practice when referals are sent too late or with the wrong diagnosis.
>
> Michael Kanter, M.D., CPPS
> Regional Medical Director of Quality & Clinical Analysis
> Southern California Permanente Medical Group
> (626) 405-5722 (tie line 8+335)
> THRIVE By Getting Regular Exercise
>
> * NOTICE TO RECIPIENT:*  If you are not the intended recipient of this
> e-mail, you are prohibited from sharing, copying, or otherwise using or
> disclosing its contents.  If you have received this e-mail in error, please
> notify the sender immediately by reply e-mail and permanently delete this
> e-mail and any attachments without reading, forwarding or saving them.
> Thank you.
>
>
>
>
> From:        robert bell <
> 0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>
> To:        IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Date:        01/02/2016 04:03 PM
> Subject:        [IMPROVEDX] Another look at Questions
> ------------------------------
>
>
>
> Dear All,
>
> I would like to thank all the people on this list who kindly responded to
> my questions a few weeks back.
>
> Since asking those questions I became aware that questions *may* be
> creative.
>
> Does it follow then that statements are less creative. I then thought how
> does that come about?
>
> A question I thought, stimulates listeners and readers to think of various
> solutions. So from one question you might get many solutions. With
> statements you would be more relying on the creativity of the writer
> presenting his or her various ideas and solutions. And these all together
> may not be great in number.
>
> With regard to the medical profession as a whole and people in positions
> of power in the healthcare industry who can effect change, one can ask do
> they ask fewer questions for fear of being considered less knowledgeable?
> So, if this is true, almost by definition, if questions are creative, such
> decision makers are less likely to be broadly creative, at least initially?
> There are obvious exceptions. So a  question might be how to better take
> advantage of the *crowd think*?
>
> This all makes an assumption that most things in medicine are complex and
> that many solutions to an issue may be necessary to arrive at a good
> solution.
>
> The IOM has issued its statement/report on diagnostic errors and there are
> some good suggestions. I was pleased to see teamwork mentioned first in
> their solution. Which essentially is an extension of *crowd think*.
>
> But the big question is where do we go from here? As you all know I would
> have preferred standard medical errors to be approached first before
> diagnostic errors. For example, I felt that if there is a significant error
> rate in radiology reports and laboratory tests that this should be
> addressed first. But assuming that we may have the cart before the horse,
> and I am not completely sure about that, what questions could be asked of
> the established consortium of speciality societies?
>
> Over and above the big structural solutions, what comes to mind for me is
> that some of these societies have issued Do and Don’t lists for their
> members.
>
> So my new question is, could those lists be looked at and the idea
> extended to all the specialty societies with the emphasis on reducing
> diagnostic error?
>
> Also, with any statement(s) would it be good to consider asking some
> questions at the end to stimulate thought?
>
> The best for 2016,
>
> Robert M. Bell, M.D., Ph.C.
>
>
>
>
> ------------------------------
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> <OSLIRetinaPDF.pdf>
>
> Robert M. Bell, M.D., Ph.C.
> P.O. Box 3668
> West Sedona, AZ  86340-3668
> USA
>
>
>
>
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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