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

Bob Latino blatino at RELIABILITY.COM
Wed Feb 21 19:07:44 UTC 2018


Thank you (as always) for your experience and well-reasoned reply.

Seems to me that you have outlined a draft priority schedule for the diagnoses that actually result in the worst outcomes.  Is that a start to trying to break 'diagnosis error' cause category down into its manageable chunks and start to analyze what system's level factors contribute to such decisions?

If the perceived consequences to the clinician are small, what is the incentive for t hem to take the time to try to be more accurate and timely in our diagnoses?

Thanks again Peter
Bob

Robert J. Latino, CEO
Reliability Center, Inc.
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From: Elias Peter [mailto:pheski69 at GMAIL.COM]
Sent: Wednesday, February 21, 2018 1:32 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] NYTimes: Her Various Symptoms Seemed Unrelated. Then One Doctor Put It All Together.

I understood the question to be, “What are the consequences TO THE DOCTOR for not making an accurate diagnosis the first time?"


  *   Having to admit “I don’t know” and run the risk of feeling competent or being considered incompetent but the patient.
  *   In a training setting (medical student, resident, fellow) there is the risk of being criticized by supervisors.
  *   In a clinical setting, there is the risk of being criticized or thought less of by colleagues, or harm to reputation.
  *   There is the concern about legal risk if negative consequences result from the delay.

Forty years as a primary care clinician led me to see this issue in somewhat separable clumps:


  *   The infinitesimally small number of cases where there were dire medical consequences for not knowing what it is and what to do, right now, this instant, in real time. OB is the classic example, with things like unsuspected breech or shoulder dystocia during delivery, or an obtunded newborn.
  *   The larger but still quite small number of cases where one is unlikely to get a second try but seconds and minutes do not count.
  *   The big chunk where first-pass diagnosis makes you feel good but doesn’t change the outcome. (A case of cutaneous anthrax is one I remember.)
  *   The very large chunk (I’d guesstimate 60% or more) where an accurate diagnosis cannot be made on the first pass without doing a large number of inappropriate tests - where time and the natural history are the best diagnostic tools. This applies to much of rheumatology, many non-specific but common symptoms: fatigue, pruritus, constipation, nausea, weight loss, insomnia, dizziness, various mood and behavior disorders, pain without findings on exam.

But, in response to the question posed by Bob Latino, I think the consequences to the clinician are generally small. (This does not apply to all areas of medicine, of course.)

Peter

On 2018.02.21, at 9:54 AM, Grubenhoff, Joe <Joe.Grubenhoff at CHILDRENSCOLORADO.ORG<mailto:Joe.Grubenhoff at CHILDRENSCOLORADO.ORG>> wrote:

I think that is condition-specific. If it’s sepsis or impending cardiac arrest from an OD, then the negative consequence is massive. If it’s pediatric lupus a few weeks to months is probably not catastrophic for the patient. The potential negative consequence to trying always be accurate on the first patient encounter is over-testing, unnecessary testing and astronomically skyrocketing cost.

Case in point: Mother brings in her well-appearing toddler with fever for 2-3 hours. No other symptoms. The possible causes are effectively (not literally) infinite and I can’t test for all of them. I can order a CBC which tells me nothing of the source or nothing at all if normal. I can order blood cultures (knowing that the ratio of true infection to contaminant is around 1:5 to 1:7). I could shoot a CXR to assess for occult pneumonia, cath the child for urine culture, etc. etc. I can use a shotgun approach and be no closer to a diagnosis after a 3 hour ER stay but have exposed the patient to a number of harms (pain, radiation, dysuria, possibly introducing an infection).

We have to balance the negative consequences of missing a dx with the negative consequences of searching for absolute certainty. And we have to explain the ambiguity to our patients. Lastly we need to help them understand that in many cases, time is a diagnostic test.

From: Bob Latino [mailto:blatino at RELIABILITY.COM]
Sent: Wednesday, February 21, 2018 9:43 AM
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.

Outsider question that may be obvious to you experts:

What is the negative consequence to the doctor for not making an accurate diagnosis the first time?
Sent from my iPhone

On Feb 21, 2018, at 11:40 AM, Elias Peter <pheski69 at GMAIL.COM<mailto:pheski69 at GMAIL.COM>> wrote:
Some years ago, I wrote a short blog piece about my approach to teaching FP residents to question both their diagnosis and their certainty:

http://petereliasmd.com/node/10


Peter Elias, MD


On 2018.02.21, at 6:44 AM, Joe Graedon <jgraedon at GMAIL.COM<mailto:jgraedon at GMAIL.COM>> wrote:

Bill,

You are a very insightful mentor and teacher. The problem is that in our time-challenged environment “discordant data” are often ignored or overlooked. Please take time to read Larry Weed’s brilliant book, Medicine in Denial. You will quickly appreciate that Art has brought Dr. Weed’s vision to reality.

On another note, we were thrilled to see that patient engagement is now a priority for ImproveDX. When patients and family members are considered equal players in the diagnostic process we could see real advances in what has been a challenging dilemma.

Joe Graedon
The People’s Pharmacy
Sent from my iPad

On Feb 19, 2018, at 12:14 PM, Follansbee, William <follansbeewp at UPMC.EDU<mailto:follansbeewp at UPMC.EDU>> wrote:
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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Fax: 412-647-3873
Email: follansbeewp at upmc.edu<mailto:follansbeewp at upmc.edu>

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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<mailto: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

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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