NYTimes: Her Various Symptoms Seemed Unrelated. Then One Doctor Put It All Together.

David Adelson adelson at OHSU.EDU
Mon Feb 19 17:48:59 UTC 2018


I want to give an unbiased plug for VisualDx for a powerful clinical decision aid for patients with skin manifestations and systemic diseases.  I was on call this week end for hospital consults, a situation where I am particularly prone to anchoring and adjusting biases.  In the acutely ill, considering what uncommon presentations, if missed would result in mortality,  scares most dermatologists out of the hospital consulting business.  My hypothesis is that it is not the disruption to the day that has left so many hospitals without i patient dermatology services, put risk aversion since most are in high volume/low complexity or surgical practices.

So we had a case of urticaria with leukocytosis and fever after taking cephalexin for cellulitis.  High probability drug rash but the fever was a higher than usual and leukocytosis higher than typical.  Another urticarial drug reaction  likely from an antiseizure med in a patient with ADEM with no known cause, a likely atypical sweets syndrome in a young women with Leukemia.  In each of these cases, even though a skin biopsy was done, it is not helpful for management in the acutely ill.  Visual DX was helpful in deciding what other tests could be done to rule out the unlikely and provide a more thoughtful consult.  I am curious, Art, if you have studied consult anxiety and aversion to in patient consults before and after adoption of VisualDX.  It seems that the information would be helpful to hospitals and other institutional subscribers and those of us who are training residents and would like them to become comfortable with such tools..

Dave


On Feb 19, 2018, at 8:17 AM, Art Papier <apapier at VISUALDX.COM<mailto:apapier at visualdx.com>> wrote:

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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