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

Grubenhoff, Joe Joe.Grubenhoff at CHILDRENSCOLORADO.ORG
Tue Apr 11 15:00:49 UTC 2017


Thanks to another list serve member for posting an interesting lay scientific press critique of the study at this link: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?A2=ind1704&L=IMPROVEDX&X=O8693BBB6E890749397&Y=joe.grubenhoff%40childrenscolorado.org&P=39672<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?A2=ind1704&L=IMPROVEDX&X=O8693BBB6E890749397&Y=joe.grubenhoff@childrenscolorado.org&P=39672>

One other thought about individuals seeking a second opinion on their own when not satisfied with the first is what that could do to the second opinion provider (SOP): That is, at the outset there is a chance the SOP is assuming that the patient is incredulous/dissatisfied with the initial provider’s diagnosis OR that the first provider was indeed wrong which may not be true. The SOP then may have an explicit or implicit bias to please the patient by confirming that the first provider was in error OR in the case of a tertiary or quartenary center, demonstrate the omniscience of the Ivory Tower and bestow a second opinion that conflicts with the first. Practicing in the Ivory Tower of a Regional Pediatric Level 1 Trauma Center, I will acknowledge a certain hubris that I often expect the “OSH” to have gotten at least partially wrong - though the vast majority of the time they got it right or just don’t have the resources to make a definitive dx. As I have been out from fellowship longer and longer, I have really come to appreciate just what providers in critical access and very rural areas are up against and they do a great job. Additionally, some people are just not satisfied hearing things like “there’s nothing but time that will make this better" (known also as the Pediatrician’s Mantra - It’s Just a Virus).

I guess the point is that both patient and provider bring certain expectations and assumptions to any encounter and these are probably heightened when seeking a second opinion. It’s incumbent upon us to maintain a certain degree of humility about our own skill, a certain degree of faith in the skill of our colleagues and remember that much of our good diagnoses benefit from the passage of time or a little luck. The inherent uncertainty in the diagnostic process demands that of us.

That’s my $0.02 for the day.

Cheers


Joseph A. (Joe) Grubenhoff, MD, MSCS
Associate Professor of Pediatrics
University of Colorado School of Medicine
Associate Medical Director, Clinical Effectiveness
Children’s Hospital Colorado
joe.grubenhoff at childrenscolorado.org<mailto:joe.grubenhoff at childrenscolorado.org>
(o) 303-724-2581 (f) 720-777-7317




On Apr 10, 2017, at 07:14, Samuel, Rana <Rana.Samuel at va.gov<mailto:Rana.Samuel at va.gov>> wrote:

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<mailto: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<mailto: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>
>>
>>
>>
>> Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
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