Fwd: PDF - www.pnas.org

HM Epstein hmepstein at GMAIL.COM
Wed Aug 31 06:54:38 UTC 2016


I found articles on the topic in PubMed but most aren't available to read
full text without a subscription. A recent study was  [J Cancer Res Clin
Oncol. 2016 Jul;
"Is there evidence for a better health care for cancer patients after a
second opinion? A systematic review."] The abstract's results section
wasn't very helpful:

*"Depending on the study, between 6.5 and 36 % of patients search for a
second opinion, due to a variety of reasons. Changes in diagnosis,
treatment recommendations or prognosis as a result of the second opinion
occurred in 12-69 % of cases. In 43-82 % of cases, the original diagnosis
or treatment was verified. Patient satisfaction was high, and the second
opinion was deemed as helpful and reassuring in most cases. Yet, data on
patient-relevant outcomes or on the quality of the second opinion are
missing." *

Perhaps if I could see the charts there would be more helpful data, but
there's a pay wall even for healthcare journalists.
​

Best,
Helene​


hmepstein.com
@hmepstein <https://twitter.com/hmepstein>
Mobile: 914-522-2116

On Wed, Aug 31, 2016 at 12:16 AM, <Michael.H.Kanter at kp.org> wrote:

> great questions.  I dont know the answers to any of these.  Part of the
> barrier of getting second opinions besides the need for second opinions not
> being recognized is the cost which can be born either by the patient or the
> delilvery system but is not trivial.
>
>
> Michael Kanter, M.D., CPPS
> Regional Medical Director of Quality & Clinical Analysis
> Southern California Permanente Medical Group
> (626) 405-5722 (tie line 8+335)
>
> Executive Vice President,
> Chief Quality Officer,
> The Permanente Federation
>
> THRIVE By Getting Regular Exercise
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> From:        HM Epstein <hmepstein at GMAIL.COM>
> To:        IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Date:        08/29/2016 12:02 PM
> Subject:        Re: [IMPROVEDX] Fwd: PDF - www.pnas.org
> ------------------------------
>
>
>
> Michael:
> You wrote, "Frequently, in practice getting a second opinion is NOT a
> routine and so the second opinion approaches the case very differently as
> he/she knows someone is questioning the diagnosis.  Of course, if a second
> or third opinion is the routine, this is not the case."
>
> Does anyone have statistics on how often a patient gets a second opinion?
> I would think it varies by specialty. Also, I expect those with a diagnosed
> illness seek second opinions more often than those without.
>
> Plus a little wishful thinking: I would love to see a study comparing use
> of second opinions between patients who are told their tests are negative
> and still have symptoms vs. those who don't. (Even that group can be broken
> down between patients who never had symptoms and those whose symptoms
> dissipated when told their test results were clean.)
>
> Thanks.
>
> Best,
> Helene
>
> *-- *
> *hmepstein.com* <http://hmepstein.com/>
> *@hmepstein*
> *Mobile: 914-522-2116 <914-522-2116>*
>
> *Sent from my iPhone*
>
>
>
> On Aug 29, 2016, at 10:37 AM, Ely, John <*john-ely at UIOWA.EDU*
> <john-ely at uiowa.edu>> wrote:
>
> 0.01 = 1%
> 0.01 x 0.01 = 0.0001 = 0.01% (not 0.001%)
>
> 0.01=1%
> 0.001=0.1%
> 0.0001=0.01%
>
> At least I think that’s right.  It actually took me a little while and my
> calculator to figure it out.  Embarrassing.  Apart from the math, I don’t
> think this would work because those 1% from the first radiologist will be
> tough cases and the second equally skilled radiologist won’t have the same
> 1% error rate for tough cases.
>
> John Ely
>
>
>
> *From:* Mark Graber [*mailto:mark.graber at IMPROVEDIAGNOSIS.ORG*
> <mark.graber at IMPROVEDIAGNOSIS.ORG>]
> * Sent:* Monday, August 29, 2016 7:31 AM
> * To:* *IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG*
> <IMPROVEDX at list.improvediagnosis.org>
> * Subject:* Re: [IMPROVEDX] Fwd: PDF - *www.pnas.org*
> <http://www.pnas.org/>
>
> Second opinions are an attractive intervention to help reduce diagnostic
> errors, but will require a LOT more study to understand when and how to go
> this route for maximal benefit and value.  As a start, second (and third,
> etc) reviews seem to be an ideal answer for all the diagnoses that depend
> on visual findings, including imaging, pathology and cytology-based tests.
> I'm just guessing that 50 years from now, cancer cytologies will all be
> read by teams of people.
>
> In general medical practice, the story is a little different.  In theory,
> if the error rate after a single reading is 1%, that could be reduced to
> 0.001% by a second reading by an equally skilled clinician.  But, if a
> patient only pays attention to the second opinion, the error rate doesn't
> improve at all.  Another factor that degrades the potential improvement is
> that most people with a 'normal' reading from the first clinician won't
> bother to get a second opinion (which would pick up most false negatives).
> The math on that gets a little complicated, but is explained here:  Lindsey
> PA, Newhouse JP. The cost and value of second surgical opinion programs: a
> critical review of the literature. J Health Polit Policy Law.
> 1990;15(3):543-570.
>
>
> Mark L Graber MD FACP
> President, SIDM  *www.improvediagnosis.org*
> <http://www.improvediagnosis.org/>
>
> <image001.png>
>
> On Aug 29, 2016, at 12:01 AM, *Michael.H.Kanter at KP.ORG*
> <Michael.H.Kanter at kp.org> wrote:
>
> I found this article really interesting.  I think there are some
> significant limitations though.
> 1)  it was confined to situations in which all of the information was made
> available to the physician (s) to make a diagnosis.  This works for images
> best but in most situations the physician when less than certain can get
> other information.  Perhaps more clinical information, lab tests, ect.
> Even in interpreting images, physicians can get more views or images prior
> to making a decision.  None of this was available in this study so the
> generalizability to the real world  is somewhat limited.
> 2)  I would agree with Linda in that having a dichotomous outcome is also
> a bit artificial.  Physicians can have an uncertain diagnosis and do close
> follow up.
> 3)  Not having discussion among the differing opinions is also artificial.
>  Ideally, in practice if there was a difference of opinions, there should
> be a discussion as to what each physician is thinking and why.  Of course,
> in some settings this may not occur as when a second opinion is obtain in a
> totally separate institution so the lack of discussion among the physicians
> in this study may reflect much of current practice.
> 4)  Frequently, in practice getting a second opinion is NOT a routine and
> so the second opinion approaches the case very differently as he/she knows
> someone is questioning the diagnosis.  Of course, if a second or third
> opinion is the routine, this is not the case.
>
> Overall, though, this article addresses the really important issue of how
> to aggregate different opinions and use the collective wisdom of the crowd.
>   I think more study is needed but this forms the basis of a theoretical
> framework that deserves more study.
>
>
> Michael Kanter, M.D., CPPS
> Regional Medical Director of Quality & Clinical Analysis
> Southern California Permanente Medical Group
> (626) 405-5722 (tie line 8+335)
>
> Executive Vice President,
> Chief Quality Officer,
> The Permanente Federation
>
> THRIVE By Getting Regular Exercise
>
> * NOTICE TO RECIPIENT:*  If you are not the intended recipient of this
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> From:        "Linda M. Isbell" <*lisbell at PSYCH.UMASS.EDU*
> <lisbell at psych.umass.edu>>
> To:        *IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG*
> <IMPROVEDX at list.improvediagnosis.org>
> Date:        08/25/2016 09:03 AM
> Subject:        Re: [IMPROVEDX] Fwd: PDF - *www.pnas.org*
> ------------------------------
>
>
>
>
> * Caution: *This email came from outside Kaiser Permanente. Do not open
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> ------------------------------
>
> Hi Mark and others -
> Ok I'll take stab at this...
> Yes, this is a complicated piece methodologically and statistically, but
> the implications you suggest (Mark) below are generally correct.  It is a
> great paper and one that I am sure psychologists especially like, but I
> think there are some important caveats to keep in mind if you were to apply
> in practice.  I'll describe them below and also try to elaborate some on
> the methods/stats as I understand them.
> First, be careful not to draw wide-ranging conclusions about how this
> might actually work in practice - that is, these were independent judgments
> from a group of doctors (for whom there were meaningful individual scores
> of diagnostic accuracy available) who diagnosed and rated their confidence
> for each of many images for which there were correct/known diagnoses (101
> radiologists for the mammograms, 40 dermatologists for the skin images) -
> images were divided into different groups for different docs so not
> everyone rated all of them (due to the large number I'm sure).  No one ever
> communicated with anyone.  Following each diagnosis, docs rated their
> confidence.  Virtual groups were created by randomly sampling up to 1000
> groups for each of the two types of images (breast and skin) AND for each
> of three different doc group sizes (2 v. 3 v. 5 doctors).  So, what they
> did is essentially create a bunch of randomly selected groups of doctors
>  by repeatedly sampling from their "population" of doctors/diagnoses (for
> these 6 "conditions" in what can be thought of as a 2 [skin v. breast
> images] x 3 [group size: 2 v. 3 v. 5 doctors] design).  So they created up
> to 6000 virtual groups (up to 1000 for each) - something I think is really
> cool methodologically!   Each doctor got a sensitivity score (that is,
> proportion of positive results identified as such) and a specificity score
> (that is, proportion of negative results identified as such).  Youden’s
> index (J) is an accuracy measure that takes into account both of these
> scores and is equal to (sensitivity + specificity) - 1.  The index ranges
> from -1 to +1 where a score of 0 means that the proportion of people
> identified with the disease is the same regardless of whether they actually
> have it or not.  A 1 means the test is perfect (no false positives or
> negatives).  For a pair of docs in any given group, a change in J was
> computed (ΔJ), which is the difference in accuracy between that pair of
> doctors.  So, basically then, when ΔJ is small, that is when docs have
> similar accuracy - based on all of the cases they judged).
> The "confidence rule" means that the doctor with the most confidence in
> his/her diagnosis in any given group "wins" on a specific diagnostic
> assessment - and that becomes the outcome/diagnosis for the group (and that
> outcome is compared to the diagnosis of the best doctor in the group - the
> one with the highest accuracy score based on all diagnoses from all images
> rated).  So, regardless of group size, it turns out that if you have a
> group of doctors who generally perform similarly well across all of their
> diagnostic assessments, then going with the diagnosis in any given
> case/image that is associated with doc who is most confident with it will
> be best/most accurate.    For groups of 3 or 5 docs, if they have similar
> accuracy levels in general, then going with the majority "vote" (diagnosis)
> is more accurate than the diagnosis of the single best/most accurate doc in
> the group.  As you can see in Figure 2 in the article, if docs aren't
> pretty similar in their overall accuracy in a given group, then they are
> MUCH better off going with the diagnosis of the best diagnostician in the
> group.
> SO that's how I read/understand all this.   The tricky part, I think,
> about applying this to practice prior to more research is that these were
> all independent judgments/diagnoses and accuracy scores were computed for
> each doc based on a large number of images that each evaluated.  This is
> how it was determined who the docs are that are similar in accuracy to one
> another.  In the real world (everyday practice), I am not sure you would
> actually know this - would you?  (I'm an outsider here - a social cognition
> expert, not an MD or clinician).  I am guessing you have a sense of who the
> good docs are who make good judgments, but I wonder how much more info you
> need about their general accuracy in order for the effects reported in this
> article to emerge in real clinical practice (in a way that is CLINCIALLY
> significant and not just statistically significant)?  There is a noteworthy
> literature in social psychology that demonstrates that group decisions can
> sometimes lead to bad outcomes and in some cases to very good ones - the
> trick is to figure out what those conditions are that take you one way or
> the other.  If group members can truly add some expertise/understanding to
> a problem, outcomes can improve.  However, much work suggests that groups
> can lead to situations in which individuals are overly influenced by others
> and thinking gets kind of stuck or overly influenced by some ideas that may
> well be wrong (which can lead to confirmatory hypothesis testing around
> those ideas if people engage in more discussion/thought, and may ultimately
> lead to premature closure either with or without the confirmatory
> hypothesis testing).  Of course much of this work also has been done with
> group discussions and interactions - something that is noticeably missing
> in the study reported in the PNAS article (but appropriately, they do note
> this in their discussion).
> Overall, it seems that in diagnostic decisions that are relatively
> dichotomous (as in this article - though I also wonder how many decisions
> really are quite this dichotomous??  If there are few, then more research
> is needed to see what happens when their are multiple
> possibilities/diagnoses/outcomes), these simple decision rules (majority
> and confidence rules) could work out well and be relatively efficient IF
> one actually knows the diagnostic accuracy of the group members and knows
> that they are similarly good.  Personally, I see that as kind of a big if
> --- because if you are wrong about this - ugh - these decision rules lead
> to MORE error than if you just went with the best doc! (Again see figure
> 2).  I guess this is where I wonder most about applying this in practice.
> SO at the moment at least, this research looks very promising to me for
> application down the road, but more work would be needed to get there and
> feel confident that the rules actually do lead to fewer errors in practice
> (and not too more errors....yikes!).  Plus that whole issue of
> communication between docs seems extremely important for practice too.
> All that said, I like the paper VERY much as an important contribution to
> basic research with the strong potential to one day to have applied
> implications - but I don't think we are there yet.
> Very interested also in others' thoughts,
> Linda
>
> ---
> Linda M. Isbell, Ph.D.
> Professor, Psychology
> Department of Psychological and Brain Sciences
> University of Massachusetts
> 135 Hicks Way -- 630 Tobin Hall
> Amherst, Massachusetts 01003
> Office Phone:  413-545-5960
> Website:  *http://people.umass.edu/lisbell/*
> <http://people.umass.edu/lisbell/>
> On 2016-08-23 12:17, *graber.mark at GMAIL.COM* <graber.mark at gmail.com>
> wrote:
> Thanks to Nick Argy for bringing this article to attention.   The methods
> and findings are a bit hard to follow, but if I understand things
> correctly, the article finds that diagnostic accuracy can be improved by
> second opinions or larger groups if the diagnosticians have similarly high
> skill levels, but that accuracy is degraded to the extent that the
> variability increases.  I'd really like to hear what others get out of this
> paper, because these findings have important implications for
> recommendations to move in the direction of getting more second opinions,
> or using the new group-based diagnosis approaches.
>
> Mark
>
>
>
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