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

Elias Peter pheski69 at GMAIL.COM
Fri Feb 23 15:43:52 UTC 2018


Thou shalt prominently post in your clinical work space a list (or graphic) of common cognitive biases, and review it daily, attempting to identify examples in your own work.

Peter


On 2018.02.23, at 7:33 AM, Ely, John <john-ely at UIOWA.EDU> wrote:

Thou shalt keep a life list or your errors and the lessons you learned from each one
Thou shalt document a differential diagnosis using a checklist rather than your memory
 
John W. Ely, MD
University of Iowa
 
From: Nonie Leonidas [mailto:nonieleonidas68 at GMAIL.COM <mailto:nonieleonidas68 at GMAIL.COM>] 
Sent: Friday, February 23, 2018 3:31 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [External] Re: [IMPROVEDX] NYTimes: Her Various Symptoms Seemed Unrelated. Then One Doctor Put It All Together.
 
Please suggest or correct any of these Commandments. I am thinking of improving it. 
Thanks, Leonardo Leonidas 
(Author of Ten Commandments to Reduce Diagnostic Errors.)
 
*
 
Ten Commandments to Reduce Cognitive Errors
 
   1          Thou shalt reflect on how you think and decide.
   2          Thou shalt not rely on your memory when making critical decisions.
   3          Thou shalt make your working environment information-friendly by using the latest wireless technology such as the iPad, Kindle, Samsung Notes, Nexus.
   4          Thou shalt consider other possibilities even though you are sure of your first diagnosis.
   5          Thou shalt include Bayesian probability and the epidemiology of the diseases in your differential diagnosis.
   6          Thou shalt mentally rehearse common and serious conditions that you expect to see in your specialty.
   7          Thou shalt ask yourself if you are the right person to make the final decision or a specialist after considering the patient’s values and wishes.
   8          Thou shalt take time to decide and not be pressured by anyone.
   9          Thou shalt create accountability procedures and follow up for decisions made.
   10         Thou shalt record in a relational data base software your patient’s problems and decisions for review and improvement.
 
Copyright Leo Leonidas 2003
 
Leonardo L. Leonidas, MD
Assistant Clinical Professor in Pediatrics (retired 2008)
Distinguished Career Teaching Award, 2009
Tufts University School of Medicine, Boston, USA
 
 
On Thu, Feb 22, 2018 at 11:06 PM, HM Epstein <hmepstein at gmail.com <mailto:hmepstein at gmail.com>> wrote:
Excellent question Megan! Few medical centers have diagnostic specialists. For example, Children’s Hospital of St. Louis used to have two dedicated pediatric specialists who would focus on one complex diagnostic case every week. They would dig through the hundreds of pages of test results, labs, radiology reports, scans, etc. and then examine the patient and try to identify what had been missed. They were very successful with the patients but lost their funding a few years ago. We need more dedicated Dr. Houses (or dedicated Diagnostic Centers) in every state without creating the iatrogenic mess House would spin off with each case. But we also need to simultaneously train the new generations of doctors in medical schools how to think critically and do a proper differential. Few are taught this in med schools. 
Best,
Helene

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On Feb 21, 2018, at 7:36 PM, Megan Golden <mgolden at MISSION-CURE.ORG <mailto:mgolden at MISSION-CURE.ORG>> wrote:

Some observations about the NYT article from a first-time poster: I am not a physician but rather the founder of a nonprofit called Mission: Cure dedicated to using innovative financing based on patient outcomes to cure disease. We are focusing initially on chronic pancreatitis (which my brother is suffering from), which is frequently undiagnosed or misdiagnosed. The diagnosis issues are exacerbated by the fact that most physicians are taught that it is a disease of alcoholics, which research has shown not to be true. I would love to get this group's input on pancreatitis diagnosis at some point, but for this post I wanted to put in my 2 cents on the Times article.
 
First, I wonder whether diagnosis is a specialty that should be done by experts that specialize in problem-solving using the range of techniques discussed on this listserv. In the article, Dr. May really wanted to and tried to determine the diagnosis but it was a doctor who is really passionate about diagnosis who "solved" the case. While we ideally want all doctors to be good diagnosticians using effective methods, it seems like the obstacles to achieving that are huge (barring some big systemic changes).
 
Second, it strikes me that the discussion of how well the doctor did seems to be independent of how the patient was feeling. This patient was seriously ill and in pain for several years. There was a diagnosis to explain her illness and (luckily) a therapy to treat it, she just needed someone who had the motivation and the skills to put the evidence together and do the problem solving. I am not blaming all of the doctors who saw her since it was a rare disease and, as people have commented, hard to diagnose. But wouldn't it be better to have a system where if a person is sick to the point of being unable to participate in normal life, and there is not a definitive diagnosis, a diagnostician is brought in right away (when she presents to her local doctors, not the teaching hospital) to figure it out? What would it take to incentivize that? 
 
Thanks for including me in this excellent discussion.
Megan Golden
 
 
 
 
 
On Wed, Feb 21, 2018 at 1:50 PM, Elias Peter <pheski69 at gmail.com <mailto: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 <blatino at reliability.com <mailto: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 <tel:(800)%20457-0645>
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www.reliability.com <http://www.reliability.com/>
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From: Elias Peter [mailto:pheski69 at GMAIL.COM <mailto:pheski69 at GMAIL.COM>] 
Sent: Wednesday, February 21, 2018 1:32 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.
 
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 <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 <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
200 Lothrop Street <https://maps.google.com/?q=200+Lothrop+StreetPittsburgh,+PA+15213&entry=gmail&source=g>
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Phone: 412-647-3437 <tel:(412)%20647-3437>
Fax: 412-647-3873 <tel:(412)%20647-3873>
Email: follansbeewp at upmc.edu <mailto: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: 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 <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://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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