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

Art Papier apapier at VISUALDX.COM
Sun Jan 14 22:03:45 UTC 2018


John, Let’s add to the discussion below,  A1, A2, A3…etc.. which I am using to symbolize the variants of common dignoses that are responsible for diagnostic error.  One of our realizations in working in developing CDS over the past 20 years is the need to account for variation of the common.  Over the past 40 years many wonderful tools have been developed to expand the differential, but such tools need to be balanced in their design with bringing forward common variants in the DDx.  When you look at closed claims, the missed diagnoses are for the most part not rare diagnoses…clinicians are missing MI, PE, Cancer, Sepsis, ruptured aneurysm, Stroke etc……these are all common diagnoses, and certainly diagnoses we all know.  Yet they are all frequently missed.  If we put aside system issues as causes, and focus on cognitive mistakes,  shouldn’t we elevate representative bias in these discussions, and our solutions?  We have memorized illness scripts based on classic presentations, not “variant presentations”.   As long as medical education is exam and board exam results focused thereby encouraging extraordinary, non-human feats of memory and processing, we will continue promote the myth that we can evaluate simultatenously for variants of common and rare diagnoses, flawlessly,  and every 20 minutes in our clinics.  The unaided human mind just will not be able to see and memorize all these variants.   In my specialty, we see frequent diagnostic error in referral from generalists, and it almost always results in comments from the referring PCP saying “I didn’t know it could look like that” or “I didn’t know it could occur there”.  A very common one for example would be a recurring group of blisters or pustules invovling the palm, diagnosed as bacterial infection, not herpes.  The referring physicians just often don’t think of herpes in unusual locations.  Variation of the common needs to be part of our calculus.  

 

Best

Art

 

Art Papier MD

CEO VisualDX

Associate Professor of Dermatology and Medical Informatics

University of Rochester College of Medicine

From: Ely, John [mailto:john-ely at UIOWA.EDU] 
Sent: Friday, January 12, 2018 9:39 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] [External] Re: [IMPROVEDX] How to convey uncertainty

 

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

 

=================================================

 

Charlie Garland

 

Senior Fellow of  <http://www.hitlab.org/people/> HITLAB (Healthcare Innovation & Technology Laboratory @ Columbia University Medical Center)

Board Member @  <http://www.creativeeducationfoundation.org> The Creative Education Foundation 

Author of Upcoming Book:  <http://www.InnovationInspiration.org> Innovation Inspiration (2018)

Developer of  <http://www.cognitivebuoyancy.com> Cognitive Buoyancy®  ("The Trigger to Innovation")  

Developer of  <http://portal.sliderocket.com/BIWIR/Cubie-TOTB> The Innovation Cube (a.k.a. CubieTM - a Critical Thinking & Creative Problem-Solving Tool) 

Certified in Advanced  <http://www.polaritypartnerships.com/consultant-list-test/2016/5/31/charlie-garland?rq=garland> Polarity ThinkingTM Conflict-Resolution Construct

 

LinkedIn:  <http://www.linkedin.com/in/innovationoutlet> http://www.linkedin.com/in/innovationoutlet

Twitter:  <http://twitter.com/innovationator> @innovationator

 

 

 

 

-------- Original Message --------
Subject: Re: [IMPROVEDX] [External] Re: [IMPROVEDX] How to convey
uncertainty
From: "Ely, John" < <mailto:john-ely at UIOWA.EDU> john-ely at UIOWA.EDU>
Date: Thu, January 11, 2018 8:33 am
To:  <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG> 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> mailto:blatino at RELIABILITY.COM] 
Sent: Thursday, January 11, 2018 5:23 AM
To:  <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG> 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> https://www.amazon.com/Communicating-Intended-Unanticipated-Outcomes-Obstetrics/dp/0787966541

 

Robert J. Latino, CEO

Reliability Center, Inc.

1.800.457.0645

 <mailto:blatino at reliability.com> blatino at reliability.com

 <http://www.reliability.com> www.reliability.com

 <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> mailto:graber.mark at GMAIL.COM] 
Sent: Wednesday, January 10, 2018 10:56 AM
To:  <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG> 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> 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 



 

 

 

 


  _____  



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

To unsubscribe from IMPROVEDX: click the following link:
 <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1 

or send email to:  <mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG> IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG

Visit the searchable archives or adjust your subscription at:  <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX


Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
 <http://www.improvediagnosis.org/> http://www.improvediagnosis.org/

 


  _____  



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

To unsubscribe from IMPROVEDX: click the following link:
 <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1 

or send email to:  <mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG> IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG

Visit the searchable archives or adjust your subscription at:  <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX


Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
 <http://www.improvediagnosis.org/> http://www.improvediagnosis.org/

 


  _____  


Notice: This UI Health Care e-mail (including attachments) is covered by the Electronic Communications Privacy Act, 18 U.S.C. 2510-2521 and is intended only for the use of the individual or entity to which it is addressed, and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. If you are not the intended recipient, any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the sender immediately and delete or destroy all copies of the original message and attachments thereto. Email sent to or from UI Health Care may be retained as required by law or regulation. Thank you. 


  _____  


 


  _____  



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

To unsubscribe from IMPROVEDX: click the following link:
 <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1 

or send email to:  <mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG> IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG

Visit the searchable archives or adjust your subscription at:  <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX


Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
 <http://www.improvediagnosis.org> http://www.improvediagnosis.org/

 

  _____  

Notice: This UI Health Care e-mail (including attachments) is covered by the Electronic Communications Privacy Act, 18 U.S.C. 2510-2521 and is intended only for the use of the individual or entity to which it is addressed, and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. If you are not the intended recipient, any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the sender immediately and delete or destroy all copies of the original message and attachments thereto. Email sent to or from UI Health Care may be retained as required by law or regulation. Thank you. 

  _____  

 

  _____  


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

To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1> &A=1 

or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG> 

Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX


Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/







Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


HTML Version:
URL: <../attachments/20180114/dfc7de9e/attachment.html> ATTACHMENT:
Name: image001.jpg Type: image/jpeg Size: 17486 bytes Desc: not available URL: <../attachments/20180114/dfc7de9e/attachment.jpg> ATTACHMENT:
Name: image002.png Type: image/png Size: 8433 bytes Desc: not available URL: <../attachments/20180114/dfc7de9e/attachment.png>


More information about the Test mailing list