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

Art Papier apapier at VISUALDX.COM
Thu Feb 22 18:57:35 UTC 2018


Mark, Thanks.  Are we in the diagnostic errors community for the most part hospital medicine oriented like our medical education system or are we thinking about diagnosis across the spectrum of care, beginning in primary care?  Are we thinking enough about all the dissatisfaction with community medicine, where measuring and feedback loops are even more broken?  My suspicion is that by defining the problem around “substantial claims data that identifies at least 3 very large ‘buckets’ that account for the majority of claims:  misdiagnosis of cardiovascular conditions, cancers, and infections.” we are missing the opportunity to think about insertion points in the flow of problem-solving, beginning in the office, urgent care or “retail clinic”. In our consulting AMC based dermatology practice we see a ton of diagnostic error, while not resulting in death or significant morbidity, the patients are extremely dissatisfied with the care that they had before we engaged with them.  I hope we are thinking about the 1 billion+ outpatient visits in the US each year, many of which have no significant morbidity/mortality, but drive incredible waste through unnecessary visits and also significant patient dissatisfaction.  Best Art

 

From: Mark Graber [mailto:Mark.Graber at IMPROVEDIAGNOSIS.ORG] 
Sent: Thursday, February 22, 2018 12:54 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] NYTimes: Her Various Symptoms Seemed Unrelated. Then One Doctor Put It All Together.

 

Adopting a formal industrial approach to solving the diagnostic error problem would be ideal, but would require much more data than we actually have.  As is probably apparent to all, measurement is our weakest link.

 

However, we do have SOME data, and we can make some educated guesses on some other issues.  For example, we have substantial claims data that identifies at least 3 very large ‘buckets’ that account for the majority of claims:  misdiagnosis of cardiovascular conditions, cancers, and infections.  Within each of these large categories, we agree that a highly desirable next step would be to define measurable aspects of diagnostic error, using an approach like this one <https://www.ncbi.nlm.nih.gov/pubmed/29380218> . 

 

And it terms of educated guesses, I’d be willing to go out on a limb and guess that republicans are responsible for as many diagnostic errors as democrats, in response to Bob’s typo below  ;<)

 

Mark

 

Mark L Graber MD FACP

President, SIDM

Senior Fellow, RTI International

Professor Emeritus, Stony Brook University 



 

 

 

 

From: Bob Latino <blatino at RELIABILITY.COM <mailto:blatino at RELIABILITY.COM> >
Reply-To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG> >, Bob Latino <blatino at RELIABILITY.COM <mailto:blatino at RELIABILITY.COM> >
Date: Thursday, February 22, 2018 at 9:12 AM
To: Listserv ImproveDx <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.

 

Thanks Peter.

 

I was asked a while back to answer some questions by SIDM about this very issue.  This is an excerpt of my answers related to this line of questioning:

 

1.	Defining Scope of Problem.  I have not been able to understand from SIDM what the definition of a Dx error actually is, therefore I cannot grasp a scope.  It seems SIDM groups all Dx error in one big bucket, as if all of the conditions would be the same or similar.
2.	Quantifying the Problem.  I don’t believe SIDM can be proactive, until they get a handle on the reactive. 

a.	Getting a grip on reaction.  I have seen no attempt to break Dx error down into manageable chunks, based on severity of outcomes.  This has been proposed by Dr. Rob Bell and myself for years, to members of the SIDM forum.

                                                               i.      Which type of Dx errors are more commonly resulting in unique types of reportable bad outcomes?

                                                             ii.      What are those reportable bad outcomes (Events)?

                                                           iii.      Can those bad outcomes (in which Dx error contributed) be grouped into Event Categories, and %’s applied to frequency of occurrence and impact/occurrence?

                                                           iv.      Can a listing then be sorted from highest to lowest showing which are the highest impact bad outcomes due to Dx error (Dx is not ‘THE Root Cause’)?

                                                             v.      Normally Pareto would apply and 20% of the types of Bad Outcomes would be occurring 80% of the time (and represent 80% of the adverse impacts).  This would define the population of worst outcomes that should be addressed first, thus breaking overall Dx Error down to manageable chunks.

                                                           vi.      Effective and disciplined RCA could then be applied to Events that are most impactful and would yield the greatest returns in the shortest period of time.

This is how we would normally approach a 'problem' from an industrial perspective.  I don't think it should be different in HC, but I am not an SME in HC.  I do know in any environment that data is necessary to define an analytical direction forward.  I do not know where you all would get such data (if it exists), but i have not seen any consensus path forward for solving 'Dx Error'.  No matter what data is available, it will be based on what is reported.  So we can rest assured the 'real' problem is a multiple of what is reported (i.e. - the under or not reported reality).

 

Perhaps I am missing it because of my lack of an 'insider perspective'? 

 

Thanks again for your patience with my questioning attitude.

Bob

 

Robert J. Latino, CEO

Reliability Center, Inc.

1.800.457.0645

 <mailto:blatino at reliability.com> blatino at reliability.com

 <http://www.reliability.com> www.reliability.com

 <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: Elias Peter [ <mailto:pheski69 at GMAIL.COM> mailto:pheski69 at GMAIL.COM] 
Sent: Wednesday, February 21, 2018 6:28 PM
To:  <mailto: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.

 

I suspect there is data about this, but I don’t have any. Perhaps others…?

 

Peter

 

 

On 2018.02.21, at 3:54 PM, Bob Latino < <mailto:blatino at RELIABILITY.COM> blatino at RELIABILITY.COM> wrote:

 

Thank you.

 

Is there any data that shows more diagnosis errors are made by a certain democratic (I.e. - young, old, certain specialty, certain type of outcome, etc.)?

Sent from my iPhone


On Feb 21, 2018, at 5:49 PM, Elias Peter < <mailto:pheski69 at GMAIL.COM> pheski69 at GMAIL.COM> wrote:

I don’t know that my perspective does more than offer a way to visualize how context plays a role, in the primary care setting.   I found it useful, though, when teaching. It provided a way to reassure learners that a key lesson to learn was not that they needed to master ‘all of medicine’ but that they needed to recognize those rare instances where one had to be right, right now, and what to do in those rare instances. Beyond that, accuracy counts more than speed. 

 

About incentives.  I would take issue with my own statement that the consequences are small, unless qualified by saying the the external consequences are small. For me, and for the clinician mentors and colleagues I have learned from and admired, the incentive was always internal and personal rather than external and structural. The best clinicians I have known have been those who were driven to find the right answer, not those driven to check the right boxes or avoid litigation. I don’t know how to make that standard. It would seem that there are two parts. First, the selection process. Second, a system that focuses on internal rather than external rewards (reversing course in many ways) and is based on transparency and valuing honest self-scrutiny, admitting ignorance and error in order to learn from them. Culture, in other words.

 

Peter

 

 

On 2018.02.21, at 12:07 PM, Bob Latino < <mailto:blatino at reliability.com> blatino at reliability.com> wrote:

 

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.

1.800.457.0645

 <mailto:blatino at reliability.com> blatino at reliability.com

 <http://www.reliability.com/> www.reliability.com

 <https://www.linkedin.com/company/958495?trk=tyah&trkInfo=clickedVertical%3Acompany%2CclickedEntityId%3A958495%2Cidx%3A1-1-1%2CtarId%3A1464096807851%2Ctas%3Areliability%20center%2C%20inc.> <image001.jpg>

 

From: Elias Peter [ <mailto:pheski69 at GMAIL.COM> mailto:pheski69 at GMAIL.COM] 
Sent: Wednesday, February 21, 2018 1:32 PM
To:  <mailto: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.

 

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 < <mailto:Joe.Grubenhoff at CHILDRENSCOLORADO.ORG> 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> mailto:blatino at RELIABILITY.COM] 
Sent: Wednesday, February 21, 2018 9:43 AM
To:  <mailto: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.

 

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 < <mailto:pheski69 at GMAIL.COM> 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> http://petereliasmd.com/node/10

 

 

Peter Elias, MD

 

 

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

200 Lothrop Street

Pittsburgh, PA 15213

Phone: 412-647-3437

Fax: 412-647-3873

Email:  <mailto:follansbeewp at upmc.edu> follansbeewp at upmc.edu

 

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This email may contain confidential information of the sending organization. Any unauthorized or improper disclosure, copying, distribution, or use of the contents of this email and attached document(s) is prohibited. The information contained in this email and attached document(s) is intended only for the personal and confidential use of the recipient(s) named above. If you have received this communication in error, please notify the sender immediately by email and delete the original email and attached document(s).

 

 

 

From: Art Papier [ <mailto:apapier at VISUALDX.COM> mailto:apapier at VISUALDX.COM] 
Sent: Monday, February 19, 2018 11:17 AM
To:  <mailto: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.

 

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> mailto:ehoffer at GMAIL.COM] 
Sent: Sunday, February 18, 2018 6:40 PM
To:  <mailto: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.

 

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 < <mailto:jgraedon at gmail.com> 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://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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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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