[EXTERNAL] Re: [IMPROVEDX] The Value of a Second Opinion at the Mayo Clinic

Samuel, Rana Rana.Samuel at VA.GOV
Mon Apr 10 13:14:00 UTC 2017


The only reason a single payer system (like the VA) would be better at reducing the frequency of diagnostic error would be if it improved communication, care handoffs and care coordination. Intuitively, it appears that a well-structured single payer system might be better vehicle for achieving these three ‘C’s than a multitude of different specialty and primary care private practices whose patients  are admitted to various independent hospitals and nursing homes as needed.

As always – the deciding factor is whether we have strong, co-ordinated systems of care. Methinks this would be inherently easier to achieve in a single payer setting, but can be achieved in any system with strong, committed leadership and appropriate resources.

Rana

Rana Samuel, MD, FCAP
Chief, Pathology and Laboratory Medicine Service (PALMS, 113)
Lead pathologist – VISN 2
VA western New York Healthcare System (VAWNYHS)
3495 Bailey Avenue, Buffalo, NY 14215
Ph:    716-862-8701
Fax:  716-862-7824
Rana.samuel at va.gov


From: Bob Swerlick [mailto:rswerli at GMAIL.COM]
Sent: Sunday, April 09, 2017 7:14 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: [EXTERNAL] Re: [IMPROVEDX] The Value of a Second Opinion at the Mayo Clinic

We have a single payer system closer to home, that being the VA health system. I do not know of any data suggesting that the frequency of diagnostic error is any better or worse within the VA. I also cannot think of any reason why a single payer system would be better at diagnostic work. Perhaps someone who suggested this could provide me with their train of thought?

Bob Swerlick

On Sun, Apr 9, 2017 at 4:33 PM, Peggy Zuckerman <peggyzuckerman at gmail.com<mailto:peggyzuckerman at gmail.com>> wrote:
Re the question if a country with a single-payer system automatically grants patients better care and better outcomes, the real question to be posed is what measures are used to do so.

In my kidney cancer world which encompasses many patients in the US, Canada and the UK, I know of many errors in diagnosis in each of them.  Much of those errors derive from the simple lack of expertise by a mix of doctors. Primary care docs don't consider the symptoms which can be reported over a long period of time, whether serious back aches (flank pain is classic symptom--but what patient uses the term "flank pain"?), anemia, or unexplained weight loss. Urologists who may operate to remove a tumor often do not complete the diagnosis with CTs and /or bone scans, and reassure the patient, "I got it all", yet they do not search out the non-localized metastases.  When that patient finally is sent to an oncologist, if ever, the oncologist may not have any idea of what to do, and may simply apply the 25 year old treatment--nothing--or use the latest newly approved drug, but with little understanding of the disease and those treatments.

All of these mistakes happen in all three of these countries.  In Canada, the province in which one lives makes a difference as to the medicines and/ior specialists available. Similar in the UK, with Scotland having far higher death rates from cancer.  The measures of treatment for diagnosed cancer patients is mandated to start at 31 days.  Yet extending out tests which diagnose, including those which should have been done simultaneously gives a reset of the clock.  So treatment does not begin in 31 days, but 31 days after 90 days of delayed testing.

Peggy z

Peggy Zuckerman
www.peggyRCC.com<http://www.peggyRCC.com>

On Sun, Apr 9, 2017 at 8:34 AM, Goldman, Bruce I <Bruce_Goldman at urmc.rochester.edu<mailto:Bruce_Goldman at urmc.rochester.edu>> wrote:
Lab accreditation is supposed to assure autopsy quality, but diagnostic accuracy is not a directly evaluated parameter-it is a really important question, especially since the primary responsibility for an autopsy is often given to a trainee.

-----Original Message-----
From: Traian Mihaescu [mailto:traian at MIHAESCU.EU<mailto:traian at MIHAESCU.EU>]
Sent: Friday, April 07, 2017 3:08 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] The Value of a Second Opinion at the Mayo Clinic

"An autopsy can reveal clinically significant diagnoses missed before death"..but, are there any data about diagnostic errors in autopsy studies?

Traian Mihaescu, MD
Clinic of Pulmonary Diseases
Iasi, Romania
https://urldefense.proofpoint.com/v2/url?u=http-3A__www.ispro.ro&d=DQIFaQ&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY53YSKuLUQRxhA&r=-7e4riqIt55t2dJrgCurSOAaZ9YfqnMopB2FIHXKJzY&m=SfdVEuqtJnQTI9F56tW2vYSsx863VpoqEHsQWBArk50&s=JH19pC8Ck33mexsqm9i2BBQPVIguU2vYL2CuhXd2xqY&e=

> The gold standard used to be autopsy. Unfortunately, the rate too low
> to be of much use today.
>
> Harry B. Burke, MD, PhD
>
> Chief, Section of Safety and Quality
>
>
> Associate Professor of Medicine
>
> Department of Medicine
>
> F. Edward Hébert School of Medicine
>
> Uniformed Services University of the Health Sciences
>
>
>> On Apr 5, 2017, at 12:45 PM, Mark Graber
>> <Mark.Graber at IMPROVEDIAGNOSIS.ORG<mailto:Mark.Graber at IMPROVEDIAGNOSIS.ORG>> wrote:
>>
>> Thanks Bridget for this KEY question.  There are indeed a few studies
>> that have done longer-term follow up of patients to determine whether
>> the second opinion was correct (referenced in the attached review
>> article) and you won’t be surprised to know that in a fraction of
>> these cases (around 10%) the original diagnosis was correct, or even
>> something not yet considered.  These long-term follow-up studies are
>> difficult to conduct but very valuable.
>>
>> Your comments also touch on another big problem in our field – what
>> is the gold standard?  There is a great deal of uncertainty even at
>> this level, given that biopsy and autopsy results are not always definitive.
>>
>> Mark
>>
>> Mark L Graber MD FACP
>> President, SIDM
>> Senior Fellow, RTI International
>> Professor Emeritus, Stony Brook University
>>
>>
>>
>>
>>
>> From: Bridget Kane <kaneb at tcd.ie<mailto:kaneb at tcd.ie> <mailto:kaneb at tcd.ie<mailto:kaneb at tcd.ie>>>
>> Date: Wednesday, April 5, 2017 at 12:49 AM
>> To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>> <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>>,
>> "mark.graber at improvediagnosis.org<mailto:mark.graber at improvediagnosis.org>
>> <mailto:mark.graber at improvediagnosis.org<mailto:mark.graber at improvediagnosis.org>>"
>> <Mark.Graber at Improvediagnosis.org<mailto:Mark.Graber at Improvediagnosis.org>>>
>> <mailto:Mark.Graber at Improvediagnosis.org<mailto:Mark.Graber at Improvediagnosis.org>>>
>> Subject: Re: [IMPROVEDX] The Value of a Second Opinion at the Mayo
>> Clinic
>>
>> One of the questions for me is “are we assuming that the second
>> opinion is the gold standard?”
>> Or how can we identify the truth, i.e. the correct diagnosis?
>>
>> Is there a stronger placebo effect following a second opinion, I wonder?
>>
>> Does anyone have any research on this, by chance?
>>
>> Thanks
>>
>> Bridget
>> On 4 Apr 2017, at 16:02, Mark Graber <Mark.Graber at IMPROVEDIAGNOSIS.ORG<mailto:Mark.Graber at IMPROVEDIAGNOSIS.ORG>>> <mailto:Mark.Graber at IMPROVEDIAGNOSIS.ORG<mailto:Mark.Graber at IMPROVEDIAGNOSIS.ORG>>> wrote:
>>
>> Just coming out – this study from the Mayo Clinic
>> <https://urldefense.proofpoint.com/v2/url?u=https-3A__www.washingtonp
>> ost.com_national_health-2Dscience_20-2Dpercent-2Dof-2Dpatients-2Dwith
>> -2Dserious-2Dconditions-2Dare-2Dfirst-2Dmisdiagnosed-2Dstudy-2Dsays_2
>> 017_04_03_e386982a-2D189f-2D11e7-2D9887-2D1a5314b56a08-5Fstory.html-3
>> Futm-5Fterm-3D.11d4a1346899&d=DQIFaQ&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY
>> 53YSKuLUQRxhA&r=-7e4riqIt55t2dJrgCurSOAaZ9YfqnMopB2FIHXKJzY&m=SfdVEuq
>> tJnQTI9F56tW2vYSsx863VpoqEHsQWBArk50&s=A37cxdq81T3k3BLLvzRBM2uveYtXpG
>> ll56AjR0LJ4Ns&e= > finds that 20% of referred patients end up with a very different diagnosis.  The findings are very similar to the results from the second opinion program at Best Doctors, as referenced in the Mayo Clinic article.  In both cases, however, these are not randomly selected patients being studied – they are patients who were concerned enough about their initial diagnosis (or lack thereof) to seek out the second opinion.
>>
>> Mark
>>
>> Mark L Graber MD FACP
>> President, SIDM
>> Senior Fellow, RTI International
>> Professor Emeritus, Stony Brook University <image001.png>
>>
>>
>>
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