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

Centor, Robert rcentor at UABMC.EDU
Mon Feb 19 20:13:28 UTC 2018


Knowing this patient’s story – also published in the JGIM - May, J.E., Blackburn, R.J., Centor, R.M. Dhaliwal, G. J GEN INTERN MED (2018) 33: 226. https://doi.org/10.1007/s11606-017-4216-6 - Pivot and Cluster: An Exercise in Clinical Reasoning – the story is greatly simplified in Lisa Sanders outstanding article.

Sometimes in clinical medicine, the first step is to realize that you have a diagnostic dilemma.  The primary author here showed incredible persistence in trying to find a diagnosis for this woman’s diverse signs and symptoms.  In the typical 20-30 minute initial visit, one cannot easily grasp the many dimensions of this woman’s presentation.

As Goop Dhaliwal’s discussion demonstrates in our JGIM article, the challenge is figuring out which signs and symptoms are key in developing a differential diagnosis.

There were no simple answers to working through this woman’s problems.  She had previous labels which always slow down how we focus on the problem.  In the fog of war (trying to diagnose this patient) many factors challenge our efficacy.  Sometimes persistence eventually gets us to the right answer.

Perhaps putting key symptoms into an AI program would help, but would we recognize all the proper inputs.

We should all try to erase previous diagnostic attempts from our minds.  This technique helps with the common diagnostic error problems – e.g., community acquired pneumonia and cellulitis.  But this patient’s story was so complex that mentally erasing previous diagnoses took time and persistence.  Bravo to the team that eventually made the diagnosis.


======================
Robert M Centor, MD, MACP

Chair-Emeritus, ACP Board of Regents

Professor-Emeritus, General Internal Medicine
UAB
FOT 720
1530 3rd Ave S
Birmingham, AL 35294-3407

Phone: 205-934-7997
Fax    : 205-975-7797
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From: Jason Maude <jason.maude at ISABELHEALTHCARE.COM>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Jason Maude <jason.maude at ISABELHEALTHCARE.COM>
Date: Monday, February 19, 2018 at 1:59 PM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] NYTimes: Her Various Symptoms Seemed Unrelated. Then One Doctor Put It All Together.

Isn’t the answer here to require a documented differential diagnosis?

If the clinicians had to document a ddx wouldn’t this stop and make them think? The most important aim should not be to get them to use a decision support tool but to get them to stop and think. If they are forced to think that may generate doubt at which point they may then feel the need to consult a decision support tool. The real problem remains ‘the illusion of knowledge’.

Regards

Jason Maude
Founder and CEO Isabel Healthcare
Tel: +44 1428 644886
Tel: +1 703 879 1890
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From: "Follansbee, William" <follansbeewp at UPMC.EDU>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, "Follansbee, William" <follansbeewp at UPMC.EDU>
Date: Monday, 19 February 2018 at 18:07
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] NYTimes: Her Various Symptoms Seemed Unrelated. Then One Doctor Put It All Together.

Art,

I agree with your thoughtful comments. I would also add, however, that for a disease like cellulitis, which I agree is frequently over diagnosed and treated unnecessarily, the answer is not going to be in decision support tools. Clinicians are just not going to consult them for such a common diagnosis. It is also to teach them how to be a little more thoughtful and analytic in their bedside decision making.   We teach trainees to use small groups of common sense but not uncommonly overlooked questions at appropriate times in the diagnostic process in a systematic fashion. In this context, one question we emphasize that they should ask themselves when considering a diagnosis is, “is there any discordant data?” Cellulitis is rarely bilateral yet many patients admitted and treated for apparent cellulitis have red and swollen legs bilaterally, ie discordant findings.  If their illness script for cellulitis includes bilateral disease, then that is a knowledge problem that also has to be addressed.

Best,
Bill


William P. Follansbee, M.D., FACC, FACP, FASNC
The Master Clinician Professor of Cardiovascular Medicine
Director, The UPMC Clinical Center for Medical Decision Making
Suite A429 UPMC Presbyterian
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Phone: 412-647-3437
Fax: 412-647-3873
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From: Art Papier [mailto:apapier at VISUALDX.COM]
Sent: Monday, February 19, 2018 11:17 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: 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<https://urldefense.proofpoint.com/v2/url?u=https-3A__www.nytimes.com_2018_02_14_magazine_her-2Dvarious-2Dsymptoms-2Dseemed-2Dunrelated-2Dthen-2Done-2Ddoctor-2Dput-2Dit-2Dall-2Dtogether.html-3Fsmprod-3Dnytcore-2Dipad-26smid-3Dnytcore-2Dipad-2Dshare&d=DwMGaQ&c=o3PTkfaYAd6-No7SurnLtwPssd47t-De9Do23lQNz7U&r=lKOUSI1VbcdcWs5U5oqgToSe5axVTFObfPeLZyyqVcM&m=UUGeQcVmDhJppozVB-uEpDXzT8mTK9AgxLZi8_1blPE&s=wBIU1zLKOsr3ICp7PwYbADxZHi0dEMmy1OA3gTDDvFM&e=>

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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