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

Tom Benzoni benzonit at GMAIL.COM
Tue Jan 16 21:48:28 UTC 2018


I can hardly assess all possibilities; I'd spend my entire time on one
patient.
This is the necessity of assessing the most likely.
Thus the need for pretest probability.
Dr. Wells has a succinct statement on the topic indexed in MDCalc on DVT
criteria.
(I prefer not to insert live links; security flag.)
tom benzoni

On Tue, Jan 16, 2018 at 8:17 AM, Jain, Bimal P.,M.D. <BJAIN at partners.org>
wrote:

> I believe the function of a differential diagnosis generator is to remind
> us of all possible diseases which may be present given a presentation in a
> patient. We evaluate every disease in the differential diagnosis regardless
> of probability till one is diagnosed definitively. And in any case it is
> not possible to incorporate prevalence, as you mention, in a differential
> diagnosis.
>
>
>
> Bimal
>
>
>
> *From:* Ely, John [mailto:john-ely at UIOWA.EDU]
> *Sent:* Monday, January 15, 2018 1:10 PM
>
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] [External] Re: [IMPROVEDX] How to convey
> uncertainty
>
>
>
> Art, 2 quick responses
>
>
>
> Current differential diagnosis generators account for best match but not
> disease prevalence, and both are needed to determine the probability of
> disease.  Even if the developers of these systems wanted to incorporate
> prevalence, they couldn’t because we don’t know what the prevalence is.  A
> big gap in our knowledge and a difficult gap to fill.  It would involve
> patient followup and diagnostic testing that might not be clinically
> indicated.
>
>
>
> There are 800,000 MI’s per year but how many cases of undiagnosed
> spontaneously resolving chest pain are there?  I suspect that number would
> dwarf 800,000.  Again, we’ll never know.  We could know, but funders don’t
> see this as an important question, and it would take huge funds.
>
>
>
> John
>
>
>
>
>
>
>
> *From:* Art Papier [mailto:apapier at visualdx.com <apapier at visualdx.com>]
> *Sent:* Monday, January 15, 2018 11:02 AM
> *To:* 'Society to Improve Diagnosis in Medicine'; Ely, John
> *Subject:* RE: [IMPROVEDX] [External] Re: [IMPROVEDX] How to convey
> uncertainty
>
>
>
> Hi John,
>
> Thanks for your thoughtful reply.  Here are some responses:
>
> 1.       Agree 100% and that is what we do, enter symptoms and other
> findings to develop a ddx, and simultaneously show which presentation is
> the best match for each Dx in the differential
>
> 2.       Yes every type of practice/specialty has a different severity
> and incidence of low or high acuity diseases.  A quick web search says
> there are 250,000 cases of appendicitis in the US/yr, and 1500 cases of
> acute intermittent porphyria.  Seems that if we knew the approx. variation
> rate of each disease we could calculate the likelihood of variant
> presentations vs rare diseases.  Approx 800,000 MI’s a year, 600,000
> strokes…just seems these numbers dwarf the rare diseases.
>
> 3.       You are correct, but the culture would change if we examined and
> credentialed doctors differently.  You create boards and exams and that is
> what students focus on.  We allow grade school students to use calculators
> in the exam, we train pilots on their instruments, but in medicine most
> still memorize the route instead of using the map and checklist.  We need
> to test and train students and residents in how to access information, so
> they continue to do that lifelong.  The good news practice is changing,
> even with medical education is slow to adapt.  There is a wide spectrum of
> behavior out there, with many clinicians using technology to aide
> decisions.  We have data to prove that.  Doctors and the culture of
> medicine are evolving use of information at the point of care will greatly
> accelerate as patients start using more and more information to guide their
> decisions.  The patients will drag many doctors by their ears into the 21
> st century, some will retire, and practice will change.  We are just late
> to the information revolution we are living through.
>
> Best
>
> Art
>
>
>
> *Art Papier MD*
>
> CEO
>
> *phone* 585-272-2630 <(585)%20272-2630>
>
> *mobile* 585-615-8245 <(585)%20615-8245>
>
> *address* 339 East Ave, Suite 410 Rochester, NY 14604
>
> *web* visualdx.com
>
> *email* apapier at visualdx.com
>
>
>
> [image: https://newoldstamp.com/editor/images/f.jpg]
> <http://facebook.com/visualdx>  [image:
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> <http://instagram.com/visualdximages>
>
> [image: cid:image005.png at 01D159E6.3E7218B0] <http://www.visualdx.com/>
>
>
>
>
>
> [image: cid:image006.jpg at 01D159E6.3E7218B0]
>
>
>
>
>
> *From:* Ely, John [mailto:john-ely at UIOWA.EDU <john-ely at UIOWA.EDU>]
> *Sent:* Monday, January 15, 2018 11:15 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] [External] Re: [IMPROVEDX] How to convey
> uncertainty
>
>
>
> 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 <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 <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@
> innovationoutlet.biz <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")
>
> Developer of The Innovation Cube
> <http://portal.sliderocket.com/BIWIR/Cubie-TOTB> (a.k.a. CubieTM - a
> Critical Thinking & Creative Problem-Solving Tool)
>
> Certified in Advanced Polarity Thinking
> <http://www.polaritypartnerships.com/consultant-list-test/2016/5/31/charlie-garland?rq=garland>
> TM Conflict-Resolution Construct
>
>
>
> *LinkedIn:* http://www.linkedin.com/in/innovationoutlet
>
> *Twitter:* *@innovationator* <http://twitter.com/innovationator>
>
>
>
>
>
>
>
>
>
> -------- Original Message --------
> Subject: Re: [IMPROVEDX] [External] Re: [IMPROVEDX] How to convey
> uncertainty
> From: "Ely, John" <john-ely at UIOWA.EDU>
> Date: Thu, January 11, 2018 8:33 am
> To: 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
> <blatino at RELIABILITY.COM>]
> *Sent:* Thursday, January 11, 2018 5:23 AM
> *To:* 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 <(800)%20457-0645>
>
> blatino at reliability.com
>
> www.reliability.com
>
> [image: 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 <graber.mark at GMAIL.COM>]
>
> *Sent:* Wednesday, January 10, 2018 10:56 AM
> *To:* 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
>
>
>
>
>
>
>
>
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> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
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>
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>
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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