What magic can teach us about our brain

Mark Gusack gusackm at COMCAST.NET
Wed Sep 7 02:27:57 UTC 2016

The Croskerry article is really nice!

I think there are a number if critical issues he presents that make our job difficult.  First, as a pathologist, I can tell you that context can dramatically change the differential diagnosis for many lesions I see.  I have been misdirected by inaccurate patient history as well as mistakes made by submitting clinicians in how they remove and submit a specimen.

Then there is a critical issue he raises with figure 5.  The issue of overlap between diseases.  This parallels the problem pathologists face as ever more sensitive screening modalities present us with ever increasing numbers of specimens form earlier and earlier disease states where our original diagnostic criteria breakdown.  This leaves us with a growing grey zone that tends to be overcalled for medicolegal and financial reasons.  This has been a particularly difficult problem for:

Breast Cancer - in particular the differentiation between atypia, DIC, and early invasive disease
Prostate Cancer - in particular the finding of minute foci of low grade cancer in the elderly who, perhaps should never have had a biopsy
And now Thyroid Cancer where the diagnosis of this disease has risen dramatically whereas rates of metastasis and death have not

I presume my colleagues in the field of cardiology are now struggling with very early ACS with high sensitivity Troponins and endocrinology with "prediabetes" because some in the field are now advocating calling a fasting glucose of 106 "diagnostic" of this new state of health.

Mark Gusack, M.D.

-----Original Message-----
From: Mark Graber [mailto:graber.mark at GMAIL.COM] 
Sent: Tuesday, September 06, 2016 9:20 PM
Subject: [IMPROVEDX] What magic can teach us about our brain

There is a wonderful story in this weeks Boston Globe on …. magic!  

We know that ‘context’ problems are one of the most common cognitive factors that leads to diagnostic error.   The Rory Staunton story (missed diagnosis of Strep sepsis) illustrated this - his story of fever and vomiting led to a diagnosis of viral gastroenteritis because those symptoms suggested a GI context.  There may be no better way to study and understand context errors than to learn about magic tricks - the illusionist creates a context for us that we believe and trust, but that is never what’s really happening.  At the least, the very fact that these magic tricks are SO convincing should be ample proof of how easily we can be mislead.  Whatever is going here has got to be very similar to what happens in the diagnostic process when we misinterpret the context of a patient’s problems.  Pat Croskerry has a paper that emphasizes this point perfectly:  Context is everything. 


Mark L Graber MD FACP
President, SIDM

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