[External] Re: [IMPROVEDX] NYTimes: Her Various Symptoms Seemed Unrelated. Then One Doctor Put It All Together.

Ely, John john-ely at UIOWA.EDU
Mon Feb 19 17:46:33 UTC 2018


Great comments Art.  The 80-20 rule (Pareto Principle) when applied to diagnosis might be more like 95-5 or 95-10.  The two percentages do not have to add to 100 because they are percentages of 2 different things.  And the percentages don’t have to be 80 and 20.  80% of sales come from 20% of clients, but 95% of the people who walk through your door with a generalized rash will have 5% of the possible causes of a generalized rash.  We can’t say the exact percent because we don’t have the denominator (How many causes of a generalized rash are there?  Depends on lumping and splitting and organizational factors.)

Schnitzler syndrome may be fun to talk about, but if we want diagnosis to be reliable instead of heroic (Don Berwick), then we have to focus on the more common missed diagnoses, which, as you say, are the more common diseases that don’t present classically.  (And also the common diseases that do present classically but are not considered because of all the cognitive biases we are subject too.)  To be reliable, we need to review a differential diagnosis rather than trying to generate one from memory.  The memory part (medical knowledge) is needed to know which things on the differential can be ruled out just based on history and physical, and which need to be ruled out with further evaluation.  That part is too much for a differential diagnosis checklist, but the differential itself is practical in real time while seeing patients.  I’ve done it many times and it was often helpful.

John

John W. Ely, MD
University of Iowa

From: Art Papier [mailto:apapier at VISUALDX.COM]
Sent: Monday, February 19, 2018 10:17 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: [External] Re: [IMPROVEDX] NYTimes: Her Various Symptoms Seemed Unrelated. Then One Doctor Put It All Together.

Likewise VisualDx had Schnitzler’s at the top of the differential, but as much as I agree that all physicians need to understand and use point of care diagnostic decision support, we should recognize that relatively rare diseases like Schnitzler are uncommon and relatively easy for decision support to “pick up”.   The real need is to handle the cases when clinicians do not know they need help, but do need help.  How do you know what you don’t know?  Uncommon diseases are uncommon, and therefore variants of common are much more common that rare diseases.   Our real challenge in decision support is to provide tools that also provide useful and valuable content around the common, and more particularly with the variants of the common so clinicians have decision support top of mind.  80-20 rule:  If 80% of diagnoses are common, then it is reasonable to assume that variants of the 80% dwarf the super rare diseases in number.  It is also safe to assume that clinicians who are in a constant rush, and bogged down by mind-numbing EHR charting exercises, will question the efficiency of using these tools.  We are focused on variation in disease presentation in our work with the goal of expanding the use of decision support beyond use for seemingly rare presentations.  We belive that the memory based training and care delivery system creates self-fulfilling prophecies where clinicians ask questions around the “classic presentation disease” scripts they memorize, but do not know the questions to ask around the related variants.  As an example,  over 100,000 people are admitted to hospitals each year for cellulitis when they do not have cellulitits.  This is a boring “story” for decision because cellulitis is common, but there is so much harm happening just from error around this single diagnosis.  How do we bend this curve and reduce unnecessary admissions while recognizing all true positives?   By focusing on commn diseases and their variants we can expand the use of decision support.

Thanks to Lisa for another wonderfully written great case and prompting discussion at SIDM !
Art

Art Papier MD
CEO VisualDx
Associate Professor of Dermatology and Medical Informatics
University of Rochester
From: Edward Hoffer [mailto:ehoffer at GMAIL.COM]
Sent: Sunday, February 18, 2018 6:40 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] NYTimes: Her Various Symptoms Seemed Unrelated. Then One Doctor Put It All Together.

This story makes a very good case for the use of computer-based diagnostic decision support systems. I entered the findings into the one with which I work, DXplain, and Schnitzler's came in ranked #1 I did not try Isabel, but would not be surprised if it also had the correct diagnosis near the top. Much easier than spending the reported "hours" in PubMed that the hero expended to arrive at the correct diagnosis.
Ed
Edward P Hoffer MD, FACC, FACP

On Sun, Feb 18, 2018 at 9:16 AM, Joe Graedon <jgraedon at gmail.com<mailto:jgraedon at gmail.com>> wrote:
https://www.nytimes.com/2018/02/14/magazine/her-various-symptoms-seemed-unrelated-then-one-doctor-put-it-all-together.html?smprod=nytcore-ipad&smid=nytcore-ipad-share

Chills, sweats, hives, achey bones — the older woman was sick for years before someone figured out the unusual disease that ailed her.


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