Boston Globe Medical Mystery

Powell, Melanie A Melanie.A.Powell at MEDSTAR.NET
Sun Dec 17 22:56:55 UTC 2017

Ed - I'm glad you brought this up. I am a member of my hospital's Patient and Family Advisory Council for Quality and Safety and one of our very active members sent a similar article to our group this morning (re: cancer diagnosis in a young adult who was told she was too young to have the diagnosis).

It would be very interesting to do a study (retrospective or prospective) asking patients if they raised a concern to their provider about an alternate diagnosis and whether this concern was heeded, then perform chart review to see if physicians who heed patient concerns: 1) refer for second opinion or 2) broaden their differential (in whatever form) diagnose more accurately and faster. [If this study has been done - please share!]

We've discussed the challenge of balancing diagnostic accuracy vs. diagnostic stewardship. We've also discussed the challenge of bias and heuristics on the cognitive process. Ed - while you were able to successfully guess the diagnosis, as you mention you had the slight advantage of knowing it was an obscure disease. How do we create these flags for ourselves (in the EHR or via CDS tools) to bolster the cognitive process so we don't have to rely on hindsight to learn how we might have gotten to the correct diagnosis?

At the DEM conference in October, Kaiser Permanente Southern California group mentioned an EHR (Epic) based "second opinion" messaging service to specialists from PCPs for urgent or routine feedback. I wonder how many of these programs exist, at what rate these consults result in a confirmed or new diagnosis, and whether merely having the option of a reliable second opinion broadens a physician's differential. It would also be interesting to routinely perform "second opinion chart audits" to determine the rate of near miss diagnostic error events (i.e. delayed or missed diagnosis that was caught via chart audit prior to patient harm). Does anyone know of a study like this (being undertaken or previously published)?

Melanie Powell, MD/MPH
Fellow, MedStar Institute for Quality and Safety
(c) 410-688-5216

From: Edward Hoffer [ehoffer at GMAIL.COM]
Sent: Sunday, December 17, 2017 3:49 PM
Subject: [IMPROVEDX] Boston Globe Medical Mystery

Today's Boston Globe had a special magazine on medical issues. Lead story, on P2, is a dramatic story of a young man whose debilitating illness took 8 years to be diagnosed. Clued strongly by the fact that this was an obscure disease, I guessed it after reading the first paragraph. More importantly, putting the symptoms from the first paragraph and one from the third into both DXplain and Isabel gave the diagnosis (#1 on DXplain list, #7 and red-flagged on Isabel's)
When will such "second opinions" become mandatory?
Edward P Hoffer MD, FACP, FACC


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