[IMPROVEDX] variations in variability

Grefe, Rosemary RGrefe at CHILDRENSNATIONAL.ORG
Fri Nov 4 17:09:35 UTC 2016


Hi,

These are all good points.  Unfortunately, we have been using many of our diagnostic tools in an inconsistent manner, then claiming the data isn’t reliable.  Many countries that are part of the GLI have gone as far as having system wide training requirements where tests and demonstrations are part of the exam.

There is always a financial consideration to anything we do in our healthcare system.  I think the study is trying to demonstrate that we are actually causing an increase in cost due to incorrect diagnosis and treatment by not following the national guidelines currently in place.

Also, what about the CLIA exclusions?

Thank you,

Rosemary

From: Kodolitsch von, Yskert [mailto:kodolitsch at uke.de]
Sent: Friday, November 04, 2016 12:54 PM
To: Society to Improve Diagnosis in Medicine; Grefe, Rosemary
Subject: AW: [IMPROVEDX] [IMPROVEDX] variations in variability

Hi,

I think that question addresses the level of medical evidence. Whenever you want to change clinical management you need data to show that this is reasonable. If you extend pulmonary function testing to large groups of patients you need to show that this is justified. A clear question can be addressed with a well-defined study that may result in improved guidelines. So I think everything is fine up to this point.

But then there is a big discussion about guideline adherence. Do physicians adhere to guidelines? What a reasons for not adhering to guidelines? What are the economic consequences of modified guideline recommendations? Is the evidence strong enough to justify a strict level I recommendation, and so on. Therefore, again we enter the field of complex systems … as stated.
☺
Best

Yskert


Von: Grefe, Rosemary [mailto:RGrefe at CHILDRENSNATIONAL.ORG]
Gesendet: Freitag, 4. November 2016 16:28
An: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Betreff: Re: [IMPROVEDX] [IMPROVEDX] variations in variability

Hi,

I am a respiratory therapist responsible for managing pulmonary diagnostic services in our system.  I have often wondered why only radiology and medical labs services were put under CLIA.  I contacted them to find out but did not receive an answer.  The premise for the creation of CLIA was to avoid adverse complications due to incorrectly collected or reported diagnostic information.  The reasoning that I have been given in conversation for the limitations on its scope have been that there is no negative consequences when diagnostic data collected in areas other than radiology and med lab are collected incorrectly or reported incorrectly.

I have attached an announcement that came out in one of my professional magazines that reports a grant that has been awarded to determine how to improve on the misdiagnosis of patients with asthma or COPD due to lack of correct diagnostic testing or any testing at all.  The amount of patients is staggering and the percentage of incorrect diagnoses  troubling.  If we add in the pediatric population and other diseases I can only imagine the impact of this problem.

What do you think about the inconsistency in oversight of all diagnostic work?   This would include cardiology, neurology, and any other specialty that relies heavily on different types of data collection but is not required to meet any national standards.

I look forward to your response,


Rosemary Grefe RRT RPFT BS
Manager, Pulmonary Diagnostics
202.476.4163
rgrefe at cnmc.org<mailto:rgrefe at cnmc.org>
111 Michigan Ave. NW
Suite 1030
Childrens National Medical Center
Washington, DC 20010



From: Hess, Dr. Donald [mailto:dhess at SUSQUEHANNAHEALTH.ORG]
Sent: Friday, November 04, 2016 6:36 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] [IMPROVEDX] variations in variability

Hello Yskert:

What are the reasons that the medical profession is structurally unable to catch-up with its own professional ideals?

Regards,

Dr. Donald Hess

From: Kodolitsch von, Yskert [mailto:kodolitsch at UKE.DE]
Sent: Thursday, November 03, 2016 4:15 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] AW: [IMPROVEDX] [IMPROVEDX] variations in variability

Dear Rob,

Yes, clearly you aim primarily at avoiding diagnostic errors.
But, I am trying to promote a view that fighting diagnostic error should be embedded in a couple of issues that go far beyond the narrow description of the problem itself.
The human cognition is always involved, but human communication, human motivation, team collaboration, labor environment, information technologies, and so on are also involved. To approach this, we need some kind of concept about how to address this system.
So, to reduce diagnostic error, we need people to get involved in really doing something about the problem:
You need to think about hospital (or other health) organizations. You need to address human behavior, not just of physicians, but also nurses, managers, transports, lab people, and so on. You need to think about leadership. Who is leader in a hospital. What do you ground leadership on. How important is it to leaders to promote patient safety, and so on. You may read the classic by Elliot Freidson, who explained in his seminal analysis of the organization of the medical profession, why the medical profession in his times (the book was published in 1970) was “structurally” unable to catch-up with its own professional ideals (see: http://press.uchicago.edu/ucp/books/book/chicago/P/bo3634980.html<https://urldefense.proofpoint.com/v2/url?u=http-3A__press.uchicago.edu_ucp_books_book_chicago_P_bo3634980.html&d=DQMGaQ&c=Zoipt4Nmcnjorr_6TBHi1A&r=iMpVRgI4Jb8qPZsZHXUj0g&m=Y0C8iH00jgms7w4Md22o6IJZXRc2QB7El9MwdRAZ_og&s=fI3kThAJVksBwRCYu6Yj50HD06QDcemjXANkY0xJvSI&e=> ). These issues are essential, I am deeply convinced.

Clearly, one can try to isolate the problem, and stick to “error” in a narrow sense. Clearly: Check-lists, IT-based solutions, supervision, checking-routines, and so on do have a definitive value. But these “narrow measures” will also not yield ground-braking results if not embedded in a commensurate organizational culture that respects the safety of patients. And again we are back to the organizational system, leadership, strategy. We do not come around a discussion of broader approaches. …
… I firmly believe … this may not be evidence-based (though Freidson indeed carried together impressive data to support this view).

You said that you thought that “making the right diagnosis was ethical within itself”. I do not think so. Making a correct diagnosis does not seem ethical as such. Only if it severs ethical purposes (which is usually but not necessarily does: The Nazi-medicine, for example, did this for criminal purposes). A correct diagnosis used as means to help a patient is ethical; striving vigorously and uncompromisingly to get to a correct diagnosis is ethical when motivated to help a patient; engaging in getting people to think about getting to better diagnostic results (like you do) is ethical, if you do this with the motivation of help patients, but it may also not be ethical in those who do it to increase their own prestige. Therefore, cultivating virtue among physicians in a hospital rather than cultivating prestige and money is important. Imagine a career-orientated physician, who only strives for avoiding diagnostic error to impress his boss rather than to help his patient. What will he do, when he is sure that sloppy work remains undiscovered by his superiors? …

We need a broader view of the problem. I insist.
☺

Best,
Yskert



Von: robert bell [mailto:rmsbell200 at yahoo.com]
Gesendet: Mittwoch, 2. November 2016 18:40
An: Kodolitsch von, Yskert <kodolitsch at uke.de<mailto:kodolitsch at uke.de>>
Cc: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Betreff: Re: [IMPROVEDX] [IMPROVEDX] variations in variability

Thanks Yskert,

Not quite sure about the question. I would go with “What are the best ways to help our colleagues make less errors in diagnosis.”

As an aside I would have thought that making the right diagnosis was ethical within itself.

Once we have clarified what we think are the best ways we can start making progress and doing something. And if  we do not get it right the first time we can change things.

And the "best ways” would include a discussion of conflicts. disclaimers, and litigation issues.

Will take a look at your link - thanks for sending.

Rob
On Nov 2, 2016, at 9:04 AM, Kodolitsch von, Yskert <kodolitsch at uke.de<mailto:kodolitsch at uke.de>> wrote:

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?”


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