Debiasing

Nelson Toussaint ntoussaint at TAMARAC.COM
Thu May 31 20:55:26 UTC 2018


May 31, 2018

3:59 PM

 

Checklists were developed in aviation for two reasons:

 

1)      Operational process to cover a flight issue such as Takeoff or one engine failed

2)      Level the decision power distribution between cockpit members at these critical times

 

The second reason allows the junior cockpit crew members to participate in decision making when items on the checklist don't seem correct.

 

I suggest that a list of 10 or so simple questions mostly about diagnosis, but a few about recommended treatment be printed on a quality card and the physician be required to hand it to the patient and suggest a dialogue on a few items.  This action empowers the patient (patient advocate) and promotes discussion.  Sometimes it is easier for the patient to ask about the treatment phase to engage the physician.

 

I looked at the patient question lists from AHRQ 2012, TIME 2016, Cleveland Clinic, Phizer 2016, LOWN Institute, Kevin MD 2010 and SIDM Patient Toolkit.  They generally go down the same path, but I doubt they appear anywhere in the physicians office.

 

Something like the following might be a recommendation:

 

Diagnosis (numbers are from SIDM list)

 

X.  Did we miss any history or known physical issues?

1. What is my diagnosis? What else could it be? (Is there more than one condition that could be causing my problem?)

2. Why do you think this is my diagnosis? From test results? From my physical exam?

X. What caused the disease or condition?

X. Have you seen this condition before?

3. Can you give me written information on my diagnosis? A pamphlet? A website?

_____________________________________________________________________

 

Treatment

 

4. Can you explain the test/treatment you want me to have?  Are there different Treatment Options?

X. What outcome should I expect?

5. What are the risks to the test/treatment you want me to have? What happens if I do nothing?

6. When do I need to follow up with you?

7. What should I do if my symptoms worsen or change, or I don’t respond to treatment?

X. What questions haven’t I asked that I should have? (If you were the patient, what would you want to know?)

 

Keep it simple - get the ball rolling.

 

I am new here, but in the year I have studied the Diagnosis Improvement issue, I have seen lots of studies, papers, data analysis, but very little that hit the front line.  Why can't SIDM print a million of these and get the ball rolling?

 

   Nelson Toussaint

 

TAMARAC LLC

860-844-0199

 <mailto:ntoussaint at tamarac.com> ntoussaint at tamarac.com

 

From: Samuel, Rana [mailto:Rana.Samuel at VA.GOV] 
Sent: Wednesday, May 30, 2018 12:11 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] [EXTERNAL] Re: [IMPROVEDX] Debiasing

 

I love it! 

 

Having just read Robert’s ‘stuck-in-a-rut’ email, I think Peggy provided us with a simple action that we can all coalesce around and promote:

‘Patients questions, including “How did you come to that diagnosis / conclusion? What else could it be?”

need to be seen as socially acceptable and appropriate in all circumstances’. 

 

Actions we could take: 

1) Lobby to have “Peggy’s Law” passed in 1 or more state legislatures. (Just brainstorming here - Maybe, add 5 minutes to each patient provider visit specifically to review the 2 Q’s above?)

2) Lobby to incorporate the 2 Q’s above in every simulated patient-provider interaction in medical school.

3) Work with the “Choosing Wisely” campaign to find a way to incorporate these questions in their next recommendations (across all specialties).

 

Rana

 

Rana Samuel, MD, FCAP

Chief, Pathology and Laboratory Medicine Service (PALMS, 113)

Lead pathologist – VISN 2

VA western New York Healthcare System (VAWNYHS)

3495 Bailey Avenue, Buffalo, NY 14215

Ph:    716-862-8701

Fax:  716-862-7824

Rana.samuel at va.gov

 

 

From: Peggy Zuckerman [mailto:peggyzuckerman at GMAIL.COM] 
Sent: Wednesday, May 30, 2018 12:59 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: [EXTERNAL] Re: [IMPROVEDX] Debiasing

 

Dear All, As a patient advocate, and all too aware of the difficulties that patients have in assessing their own diagnosis, much less the reasons for that diagnosis, I have long contended that patients need to learn to ask a few simple questions.  Moreover, these questions need to be understood as both socially acceptable and appropriate in any circumstances.  That simple question, "How did you conmake that diagnosis?", followed by, "What else could it be?", would open the dialog between the patient and physician.  Inherent is that exchange is the assumption that there could be a clearly stated rationale for the diagnosis, while also acknowledging that there is always uncertainty in a diagnosis.  

 

Peggy Zuckerman

PS  Had I asked that magic question, "What else could it be?", would my 10 cm renal tumor have been found sooner?  And if I had asked  "How did you make that diagnosis?", would I have been shown the pathology report with 'no frank ulcer'? 




Peggy Zuckerman
www.peggyRCC.com

 

On Tue, May 29, 2018 at 6:03 PM, Mark Graber <Mark.Graber at improvediagnosis.org> wrote:

 

FYI …..Attached is a new systematic review of “debiasing” from both medical and non-medical literature.   Most studies found that various debiasing techniques were successful, for example by ‘considering the opposite’.   

 

Several individuals, myself included, have advocated that using an approach like “What else could this be?” would be useful in combatting diagnostic errors related to premature closure, inappropriate anchoring, framing effects, and other tendencies.  Although the article doesn’t mention this particular debiasing approach, the generally positive findings for debiasing in general seems to be a positive thing.

 

   Mark

 

Mark L Graber, MD FACP

President, SIDM

Senior Fellow, RTI International

Professor Emeritus, Stony Brook University, NY



 

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Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
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Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX


Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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