Beyond biases?

robert bell rmsbell200 at YAHOO.COM
Fri Feb 10 03:32:35 UTC 2017


Superb post Dr. Regan.

You have a lot of insight into what makes things go right and also wrong.

We are constantly making changes and those changes often are not in the interests of patients.

Communication time is the most important thing in any hospital.  But we have lost the time reviewing films with the radiologist, we have lost the CME lunchtime presentations (clinical conferences you mention) that gave us communication cells and information to stay up to date. And Bob Latino rightly points out that we do not concern ourselves to any great degree about what precisely causes an error. 

Most hospitals do not collect accurate error data and have little knowledge of whether practice changes reduce deaths or injuries. Because of the litigation situation that is most often a non-discussion area in most hospitals. And as a non-discussion area it is a forgotten area. We have no idea whether we are killing off 100,000, 200,000 or 300,000 patients a year.  We should be shouting about our successes from the rooftops.

To me there seems to be far too much talk and very little action with the support societies devoted to improving medical care and preventing errors. And I do acknowledge that it is difficult to do anything valuable in the current US medical environment.

We need to do something NOW.

You say, "For each of these categories there needs to be a set of diagnostic exercises (for the problem), a plan to improve and a monitoring method to assess the improvement." I agree.

Take any topic and do studies, just like Dr. Peter Pronovost undertook a study at Johns Hopkins that, in turn, led to a multi-center study in Michigan using his five-point checklist to ensure proper, sterile insertion of central venous catheters. The study was immensely successful:
1,800 lives and $100 million were saved during the 18 months of the study. Yes 1,800.  We have no idea of how many further lives we could save with good systems and less errors. The average study we do may not be as expansive and elaborate as Dr. Pronovost’s - but he does provide a beacon of light to improve things.

Dr. Regan your idea of the lack of good knowledge about lab testing would make a good study. Perhaps a multi-choice exam for residents (maybe with the help of one of the specialty societies that design exams, or even those statisticians in the pharmaceutical industry to get the design correct). And then training and further testing to measure improvement. I think that you could help patients no-end.  Perhaps start with a mock up exam with half a dozen residents to see if the idea seems viable. Just some thoughts

But, we do need to show that things work like Dr. Pronovost.

But how can we get everyone on the Do Something bandwagon?

How do we move forward to achieve that goal?

Thanks again for the great post. Keep writing!

Robert Bell, M.D. Ph.C.

> On Feb 8, 2017, at 6:51 PM, Regan, Elizabeth <ReganE at NJHEALTH.ORG> wrote:
> 
> I think that it is important to recognize that there is a lot of “pig-headedness” in diagnostic error.  We (as a group) spend a lot of time thinking from the point of view of academic physicians who are strongly invested in diagnostic excellence.  Unfortunately, the real world is very different.
> The really awful diagnostic errors like those that Jason points out are compounded and may be more common in closed systems that have a culture that resists the concept that rare diseases actually happen.  For me, the exciting and engaging aspect of medicine is the concept that any patient who walks/rolls into my exam room may have something different, unusual, interesting – and it is my job to sniff it out.  I need to use all of my experience, skills and knowledge to do that.  This excitement and engagement does not mean that I waste time, money, energy on useless directions – it means that I think about the problem and try to plot a strategy.  And I talk with the patient about what I am considering, why I would defer certain tests now and why I want them to return and report how they are doing.
>  
> If you are convinced that your patients are boring and have the same old URI, diabetes checkup, back pain …. Whatever.  Then you are not looking or thinking about the “possibles” and are extremely unlikely to find them.  
> I suspect that the 5 yo with juvenile arthritis was ignored repeatedly because no one imagined the possibility.
>  
> 20 visits is unconscionable.  Absolutely, a flag to identify patients like that would be a really good way for a health care system to make sure that bad things aren’t missed. 
> But why isn’t that already part of the system?
>  
> I think that we have abandoned the clinical conferences and interactions that used to be part of medicine.  They were lost to a desire to have “lifestyle” and the oft repeated “I don’t want to stay later in the day so I can attend a noon conference”.  And with the horribly inefficient administrative processes – there really is less time.  
>  
> Then there are concerns about are we training physicians properly – or just asking them to do computer data entry and refer patients for screening tests.  I find that I can’t get primary care physicians to leave their screening agenda (that they may get a monetary bonus for completing) and deal with my real needs (the stuff on my problem list) and think about me as an individual.  This is the idea behind personalized medicine – “me and my genome and how I am manifesting disease now that I am 63”.  I fear that young physicians in training are not having enough exposure to differential diagnosis and too much exposure to how to code diagnoses and the mechanics of a visit.  I am also concerned that we have produced so much literature/conversation about un-necessary testing that they are afraid to consider a less common diagnosis for fear that they might order a test that is negative.  I lump this into a term “dumbing down” the diagnostic problem where only the common causes are considered.
>  
> The number of times I have encountered physicians who are just plain wrong in the way that they interpret a test result or perform a diagnostic physical exam is shocking.
>  
> When I had an episode of motor loss due to an autoimmune problem  - 4 out 7 examiners failed to identify the motor deficit and didn’t know how to properly do an exam to evaluate the problem.
> I was shocked.
> One of them was a resident – so I offered to show him how to do the exam properly.  He wasn’t interested.
>  
> I have had a number of physicians mis-interpret the results of diagnostic testing for family members, children, and myself.  For example: a test that is positive in 60% of patients with a known disease – you cannot say that a negative test means that the patient does not have a condition.
> A rapid strept test that is negative – does not mean that one has excluded the diagnosis of a strept infection.
> Resistance to testing symptomatic patients for a disease – and not understanding that the metrics for predictive values are totally different from what is published about screening healthy asymptomatic people.
> The list goes on endlessly
>  
> I know so many good and careful physicians  - and even when they try their best – they can’t always be perfect.  However, as a profession we have a bigger problem and that includes: systems that do not support diagnostic accuracy, staff that do not facilitate communications, physicians who are lazy, poorly trained and disinterested – and with time/thought we could generate a bigger list.
>  
> For each of these categories there needs to be a set of diagnostic exercises (for the problem), a plan to improve and a monitoring method to assess the improvement.
>  
> Sorry for the Rant.
>  
> The conversation has been stimulating.
>  
> Liz
>  
> Elizabeth A. Regan MD, PhD
> Associate Professor of Medicine
> National Jewish Health
> 1400 Jackson St, K706
> Denver, CO 80206
>  
>  
> From: Jason Maude <jason.maude at ISABELHEALTHCARE.COM <mailto:jason.maude at ISABELHEALTHCARE.COM>>
> Reply-To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Jason Maude <jason.maude at ISABELHEALTHCARE.COM <mailto:jason.maude at ISABELHEALTHCARE.COM>>
> Date: Tuesday, February 7, 2017 at 12:22 PM
> To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
> Subject: [IMPROVEDX] Beyond biases?
>  
> These 2 tragic cases of misdiagnosis have been reported recently by the Daily Mail:
>  
> 1.      The first is a 5 year old boy with a missed diagnosis of juvenile arthritis  http://www.dailymail.co.uk/news/article-4198822/Boy-died-arthritis-two-years-misdiagnosis.html <http://www.dailymail.co.uk/news/article-4198822/Boy-died-arthritis-two-years-misdiagnosis.html>
> 2.      The second covers a 24 year women with a missed diagnosis of brain tumor http://www.dailymail.co.uk/health/article-4172188/Fit-intelligent-woman-24-dies-brain-tumour.html <http://www.dailymail.co.uk/health/article-4172188/Fit-intelligent-woman-24-dies-brain-tumour.html>
>  
> The most significant aspect of both these cases is that in the first the patient was seen 20x over 2 years by clinicians and in the second 14x over 9 months! 
>  
> With this number of visits we must have gone beyond ‘biases’ to just plain pig headedness!
>  
> These cases show how the most effective and simple trigger to catch potential cases could be one that flags up re attenders for the same problem for a complete rethink.
>  
> Regards
> Jason
>  
> Jason Maude
> Founder and CEO Isabel Healthcare
> Tel: +44 1428 644886
> Tel: +1 703 879 1890
> www.isabelhealthcare.com <http://www.isabelhealthcare.com/>
>  
> 
> 
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