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

Ely, John john-ely at UIOWA.EDU
Mon Jan 15 16:15:05 UTC 2018


All great points Art.  Some reactions:

1.  I totally agree that variants are important to include in any discussion of any disease, and that these variants are often ignored in information resources (VisualDX being a rare exception).  But it might be even more helpful to start with symptoms rather than diseases.  So instead of listing the different ways herpes can present, we could list the different causes of blisters in the palm, listed in order of prevalence, and with the distinguishing features of each.  What distinguishes herpes from bacterial infection, candida, dyshidrosis, and scabies?

2.  Also agree that missed diagnoses (MI, PE, cancer, sepsis, ruptured aneurysm and stroke) are not rare.  But they are relatively uncommon in primary care.  These diseases probably account for less than 1% of patients with the symptoms they typically present with (chest pain, abdominal pain, fever, etc.)  By far, the most common cause of all these symptoms will be some benign, spontaneously resolving disease that never gets definitively diagnosed.  Next most common will be benign diseases that do get diagnosed, like chest wall pain, abdominal wall pain, reflux esophagitis, benign viral infections, and so on.  Specialists are less likely to see these patients and of course they are never presented at M&M, so we get a distorted view of their prevalence.  The chance that a patient with an atypical presentation for MI will actually have an MI is probably even lower than 1%.

3.  Also agree that we are crazy to depend on the unaided human mind to memorize all the variants or even to reliably generate a comprehensive differential diagnosis.  But that craziness is deeply embedded in our culture as physicians.  Generating the differential diagnosis from memory is what we do.  Just look at any interaction between a teaching physician and a trainee -- whether it be one-to-one, or small group, or big lecture.  We ask the trainee to generate the differential from memory.  And we do the same in real time with real patients.  It’s terribly unreliable and dangerous but it’s who we are.

John

John Ely, MD
University of Iowa

From: Art Papier [mailto:apapier at visualdx.com]
Sent: Sunday, January 14, 2018 4:04 PM
To: 'Society to Improve Diagnosis in Medicine'; Ely, John
Subject: RE: [IMPROVEDX] [External] Re: [IMPROVEDX] How to convey uncertainty

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<mailto: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 HITLAB<http://www.hitlab.org/people/> (Healthcare Innovation & Technology Laboratory @ Columbia University Medical Center)
Board Member @ The Creative Education Foundation<http://www.creativeeducationfoundation.org>
Author of Upcoming Book: Innovation Inspiration<http://www.InnovationInspiration.org> (2018)
Developer of Cognitive Buoyancy<http://www.cognitivebuoyancy.com>®  ("The Trigger to Innovation")
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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 01D38DE9.B64F8F00]




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