[External] Re: [IMPROVEDX] How to convey uncertainty

Ely, John john-ely at UIOWA.EDU
Fri Jan 12 14:39:15 UTC 2018


Good point Charlie.  I think the key is that A is different from B and C.  Typically, A is the common benign diagnosis, whereas B and C are the uncommon more serious diagnoses.  The problem is not that I have failed to rule out A.  The problem is that I have not even considered B and C.  And C is the correct diagnosis, but it’s not even on my radar screen.  Also I can’t rule out A because A is the common cold.  B is pneumonia and C is meningitis and they both can be ruled out – possibly by history and physical, possibly by testing.

Studies by Mark Graber and Gordy Schiff found that the most common cause of diagnostic error is the failure to ever consider the correct diagnosis.  It’s not that we consider it and reject it.  It’s that we never consider it.  That’s what the differential diagnosis checklist is for.  It’s a cognitive forcing strategy to make us consider the correct diagnosis.  We still might mistakenly reject it, but at least it gets us over the first hurdle.

But as Atul Gawande said, “We don’t like checklists . . .  It somehow feels beneath us to use a checklist, an embarrassment.  It runs counter to deeply held beliefs about how the truly great among us – those we aspire to be – handle situations of high stakes and complexity.”  We consider checklists as crutches for the feeble minded.  Fortunately, the airline industry put a higher priority on reliability and safety than it did on the egos of pilots, who also initially rejected checklists.  One way to counter the feeble-minded concern in medicine is to encourage the physician to generate the differential diagnosis and primary diagnosis from their memory first and communicate these to the patient before using the checklist.  The checklist is just a method to make diagnosis more reliable.

Thanks for your interest and comments.

John


From: Charlie Garland - The Innovation Outlet [mailto:cgarland at innovationoutlet.biz]
Sent: Thursday, January 11, 2018 10:24 AM
To: Society to Improve Diagnosis in Medicine; Ely, John
Subject: RE: [IMPROVEDX] [External] Re: [IMPROVEDX] How to convey uncertainty

John, for the most part I agree with your response.  However -- as you've stated it -- might not what you've put forth be fundamentally biased?  If you see the "need" to rule out B and C (and not prepared to rule out A, just as readily), that seems to be an example of confirmation bias, at the very least.  At least that's how it strikes me.

I don't think you're at all wrong for beginning with the probability that A is the correct Dx.  One needs to embrace a "both/and" (subjective and objective) orientation here.  I'm just curious whether the subtlety of how our logic is developed and presented ought to be at least a red flag for consciously considering the involvement of one or more biases.

Charlie

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Charlie Garland

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Author of Upcoming Book: Innovation Inspiration<http://www.InnovationInspiration.org> (2018)
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-------- Original Message --------
Subject: Re: [IMPROVEDX] [External] Re: [IMPROVEDX] How to convey
uncertainty
From: "Ely, John" <john-ely at UIOWA.EDU<mailto:john-ely at UIOWA.EDU>>
Date: Thu, January 11, 2018 8:33 am
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
The best option may be a combination of the two implicit strategies:  “You child’s belly pain is probably due to Disease A, but could also be due to Disease B or Disease C.  And this is what we need to do to rule out B and C.  And before you leave, I just want to run through this checklist of other possibilities to be sure I’m not forgetting anything else that we need to rule out.”

John Ely, MD
University of Iowa

From: Bob Latino [mailto:blatino at RELIABILITY.COM]
Sent: Thursday, January 11, 2018 5:23 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [External] Re: [IMPROVEDX] How to convey uncertainty

Along these lines some friends of mine wrote this book a while back 'What Do I Say?' that addresses these uncomfortable conversations that need to take place between a physician and a patient.  This is targeted to obstetrics but the basic premise is about communicating information to people that otherwise would not want to hear it (bad news).

https://www.amazon.com/Communicating-Intended-Unanticipated-Outcomes-Obstetrics/dp/0787966541

Robert J. Latino, CEO
Reliability Center, Inc.
1.800.457.0645
blatino at reliability.com<mailto:blatino at reliability.com>
www.reliability.com<http://www.reliability.com>
[linkedin logo signature file]<https://www.linkedin.com/company/958495?trk=tyah&trkInfo=clickedVertical%3Acompany%2CclickedEntityId%3A958495%2Cidx%3A1-1-1%2CtarId%3A1464096807851%2Ctas%3Areliability%20center%2C%20inc.>

From: Mark Graber [mailto:graber.mark at GMAIL.COM]
Sent: Wednesday, January 10, 2018 10:56 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] How to convey uncertainty

Congratulations and thanks to Viraj Bhise and Hardeep Singh’s group for their novel study on the best way to convey uncertainty to patients about the diagnosis – advice we can use every day.

https://academic.oup.com/intqhc/advance-article/doi/10.1093/intqhc/mzx170/4791877


Mark L Graber MD FACP
President, SIDM
Senior Fellow, RTI International
Professor Emeritus, Stony Brook University
[cid:image002.png at 01D38B7F.2A764DA0]




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