AW: [IMPROVEDX] [IMPROVEDX] variations in variability

Kodolitsch von, Yskert kodolitsch at UKE.DE
Wed Nov 2 16:04:11 UTC 2016


Dear Rob,

I understand your question in essence as the following: “How can we make people act in a desirable way?”
Or: How can we make people go from “is to ought” (David Hume), which may also be formulated as the question “how can we put ethical demands into medical practice?”
Our research in this field of questions provides the following basic answer: The method to put ethical demands into medical action is strategy. Strategy is a means-end rational approach to social action. We follow the strategy approach of putting ethical principles (https://global.oup.com/academic/product/principles-of-biomedical-ethics-9780199924585?cc=de&lang=en&) into action. We distinguish the individual level (individualized medical strategies; IMS), the organizational level (organizational medical strategies; OMS), and social-political level (social-political medical strategies; SMS). We develop management tools for decision-making (such as I-SWOT, as communicated in my previous mail), teaching (3DS, in preparation), and so on.
We try to draw attention to this approach within the “IMPROVEDX community”. But our apprehension is, that it will take time to convince the IMPROVEDX community that “error” is only one “symptom” of a “complex disease”, that has to be cured by a comprehensive strategy approach that defines medical goals first and then addresses all system levels to approach solutions. Loss of a clear ethical orientation in our profession may be a bigger problem (as moral stance of constant “self-criticism” is a panacea against “cognitive errors”) in flawed diagnosis (and even more: treatment) than “cognitive error”, loss of clear purpose of hospital organizations is another, incentive-based leadership, economized concepts of quality, “clinical governance” without “organizational governance”, out-put controlled hospitals, and so on are others …
We really need a new scientific  groundwork for medical action, and we believe that the strategy approach is a relevant commitment in providing such groundwork.
So, Rob: Maybe you can spend some of your valuable time to study IMS (see attachment or https://www.cogentoa.com/article/10.1080/2331205X.2015.1109742) seriously and contribute to the evolution of ambitious approaches to profound solutions of your question by providing your sincere criticism (which is always necessary and justified in any peace of theory that deals with the human condition).

With warm regards,

Yskert



Von: robert bell [mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG]
Gesendet: Mittwoch, 2. November 2016 05:12
An: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Betreff: Re: [IMPROVEDX] [IMPROVEDX] variations in variability

All this makes me think!

Has the Improve Diagnosis Society decided on the most effective way to influence our colleagues in medicine with the best ways to reduce errors in diagnosis?

This could be anything from bold facts (a list of the biggest errors known), to an analysis of guidelines with recommendations focussing on diagnostic errors, to a multi-pronged approach.

Knowing how we think is the best way to communicate and how this should be done could then allow one to work back and start taking one disease at a time.

Within all of this the litigation issues should be well discussed - can these be controlled with appropriate disclosures?

Have there been any preliminary discussion on all of this?

I am an advocate for doing something now or soon. So how can we get there and start doing something very positive.

Also, are there conflicts with the consortium of Professional Societies that could influence the Societies actions/recommendations? Is it this conflict that leads to so many different guidelines?

If a problem, does this need to be addressed so that the Society can become more relevant?

Rob Bell, MD



On Nov 1, 2016, at 5:58 PM, Elias Peter <pheski69 at GMAIL.COM<mailto:pheski69 at GMAIL.COM>> wrote:

Thank you. I enjoyed reading the attachment(s).

I have long objected to the presentation of benefits and risks. Implicit in this phrasing is that benefits are real things that happen and risks are the possibility of bad things. Benefits and harms or potentials for benefit versus harm would be more balanced.

I-SWOT not only addresses this, but does so in a way that makes it usable.

Peter


On 2016.11.01, at 5:31 PM, Kodolitsch von, Yskert <kodolitsch at UKE.DE<mailto:kodolitsch at UKE.DE>> wrote:

Dear Joe,
Dear Peter,

an interesting line of discussion, indeed. We may add still another line:
I work at the Hamburg University Heart Center. Therefore, we deal with other settings than Peter, and we have a different but also important view on evidence and guidelines: We usually deal with highly complex and high-risk pathologies with well-defined therapeutic options, where evidence and good guidelines are available. The major problem for us is to apply well-defined standards to individuals. Indeed, there is no method that provides good ways to accommodate standards to individuals appropriately.
Therefore we developed a new approach, which we call I-SWOT. We apply this method in our case-conferences, and it really works quite well. I attach our first paper on the method. Maybe some of you will find it useful. Probably, I-SWOT performs best in high-performance medicine operating at high stakes. Nonetheless, the methods adds a new perspective on how the gap between standard and individual can be closed elegantly by applying defined methods rather than “judgement” and “intuition” alone.

Best

Yskert


Von: Grubenhoff, Joe [mailto:Joe.Grubenhoff at CHILDRENSCOLORADO.ORG]
Gesendet: Dienstag, 1. November 2016 21:45
An: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Betreff: Re: [IMPROVEDX] variations in variability

An interesting line of discussion. There are some guidelines that seem incredibly evidence-based (e.g. which kids need a head CT to rule out serious IC injury after head trauma) versus those where there is little (and often conflicting evidence) to support recommendations (Zurich Concussion guidelines). Somehow we manage to beat our colleagues over the head with both types (usually in hindsight Monday-morning QBing) and never acknowledge their flaws. I agree that they are starting point but must be thought of as guides and not prescriptive.

An interesting article worth reading on this subject comes from Greenhalgh and colleagues:
Greenhalgh T, et al. 6 Biases against patients and carers in evidence-based medicine. BMC Medicine (2015) 13:200

I attached as it is open access I believe.

So much of the evidence that informs these guidelines is driven by RCTs in which the study design drives out the variability in the participant population in order to study the intervention in isolation yet that group almost never represents our patient population.

<image001.jpg>
Joe Grubenhoff, MD, MSCS| Associate Professor of Pediatrics
Section of Emergency Medicine | University of Colorado
Children's Hospital Colorado
13123 East 16th Avenue, Box 251  |  Anschutz Medical Campus  |  Aurora, CO 80045 | Phone: (303) 724-2581 | Fax: (720) 777-7317
joe.grubenhoff at childrenscolorado.org<mailto:joe.grubenhoff at childrenscolorado.org>

Connect with Children's Hospital Colorado<http://www.childrenscolorado.org/> on Facebook<http://www.facebook.com/childrenshospitalcolorado> and Twitter<http://twitter.com/childrenscolo>

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For a child’s sake…
                We are a caring community called to honor the sacred trust of our patients, families and each other through
                humble expertise, generous service and boundless creativity.
…This is the moment.

From: Sommers, Lucia [mailto:Lucia.Sommers at UCSF.EDU]
Sent: Tuesday, November 01, 2016 1:43 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] variations in variability

My guess is with the habits you describe, Peter, and those of your colleagues, you will be sorely missed!
To what degree do you think in today's primary care world this type of collaborative engagement goes on?
To encourage it in the San Francisco Bay Area, through the Family & Community Medicine Department at UCSF, over ten years ago, we developed 'Practice Inquiry Colleague Groups' where primary care clinicians get together regularly in their practices to discuss case-based dilemmas and hear follow-up on cases previously presented.
Of course we struggle with getting people to give up a lunch hour once or twice a month to do it.  Incentives in some of the groups (e.g., Kaiser sites) offer free lunch and CME; a couple of the Sutter Health System sites let clinicians block their schedules for up to two patients. (At the latter site, the admin types see this as burn-out prevention.)

Lucia Sommers


From: Elias Peter [mailto:pheski69 at GMAIL.COM]
Sent: Tuesday, November 01, 2016 11:46 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] variations in variability

I retired from active practice at the end of 2015, and have not yet accustomed myself to taking in the past tense.

Our practice was tight knit and we had these conversations regularly, in hallways, over lunch, at the end of the day, and at our almost-monthly journal clubs. It started as a daily habit when there were only 2 of us and we had to ‘sign out’ inpatients and active outpatients at the beginning and end of every day. We grew to 10 clinicians and eventually used our local hospitalist team and stopped doing inpatient work, but the habit had become part of our culture and persisted. We daily discussed a patient or two with a colleague and frequently presented a patient to one or two others. We often saw each other’s patients to meet patient needs or deal with acute illness, which also generated discussions. On occasion we would have the patient formally see someone else in the practice specifically to get a different perspective.

These were both prospective and retrospective discussions, and we discussed victories, defeats, and errors.

Peter

On 2016.11.01, at 2:35 PM, Sommers, Lucia <Lucia.Sommers at ucsf.edu<mailto:Lucia.Sommers at ucsf.edu>> wrote:

Peter, do you ever have the opportunity of talking about these ' carefully considered individual decisions (made collaboratively with patients)' with your practice colleagues? This could be either to get their input before you go forward with a decision or after the fact, like sharing practice anecdotes. I'm wondering about whether talking more about how we do this blending of evidence and experience in the context of real cases wouldn't help validate this critically important skill.

Lucia Sommers



Sent from my iPad

On Nov 1, 2016, at 11:14 AM, Elias Peter <pheski69 at GMAIL.COM<mailto:pheski69 at GMAIL.COM>> wrote:
If there was anything I have learned from 40 years in primary care, it is that guidelines represent the opinions of a group of people who have read and are informed by the evidence. The evidence is always incomplete and always changing, often not applicable to individuals who differ from study groups, and sometimes biased. Neither the evidence nor the guidelines can incorporate the values, preferences or resources of individual patients.

For me, this was both one of the great challenges and one of the great joys of primary care: using the guidelines and the evidence) to start a conversation with a patient about what decision we should make. I never see the guilders as an answer, always as an opening statement.

Sorry for the rant, but many years of being admonished or punished by administrators, insurers, QI committees because of carefully considered individual decisions (made collaboratively with patients) that were deemed ‘out of compliance’ or 'poor care' has left me with a very sensitive and exposed nerve.

Peter

On 2016.11.01, at 1:30 PM, Twest54973 <000000040134e744-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:000000040134e744-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>> wrote:

Guidelines are ideally based on prospective data not just opinion or biologic plausibility
When adequate data doesn't exist ( as is the case for VTE prevention in pregnancy), then different people and organizations create different "guidelines" based on their beliefs and biases

Its a shame (but not unexpected) that different professional associations act independently of each other : this  results in confusion in clinicians and even sometime active conflict between clinicians

A contrary editorial accompanied the Natl Partnership article ...

Good luck to the bedside clinician trying to provide good clinical care!

Thomas Westover MD
Asst Professor Maternal Fetal Med and Obgyn
Cooper Medical School
NJ


Sent from my iPhone

On Nov 1, 2016, at 10:13 AM, Tom Benzoni <benzonit at GMAIL.COM<mailto:benzonit at GMAIL.COM>> wrote:
A topic for awareness/discussion is guidelines.
They need to support the person on the sharp end of the process, the practitioner advising the patient.
So is it acceptable that there is variation among guidelines for the same condition?
Would this be acceptable in other high risk industries?
An example crossed my desk this morning:
Comment
The variability among professional societies' recommendations for VTE prevention in pregnancy has hampered attempts at quality improvement. The NPMS challenges obstetric units to adopt all the features of this bundle in an endeavor to reduce the burden of maternal morbidity and mortality, both of which are disproportionately borne by poor women and those of color. Ideally, efforts to streamline recommendations and encourage measurement of important outcomes will promote equity and excellence in maternity care.
http://www.jwatch.org/na42624/2016/10/28/another-maternal-safety-bundle-obstetric-venous?ijkey=VLA13UO7mZVBs&keytype=ref&siteid=jwatch&variant=full-text
Is it not abrogation of responsibility to push this off onto the practitioner?
How do you reconcile this?
(There are legion examples of this in medicine.)
tom



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<aorta-03-098.pdf><Sachweh-2016-I-SWOT as instrument.pdf>--

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