Debiasing

Peggy Zuckerman peggyzuckerman at GMAIL.COM
Thu May 31 22:17:13 UTC 2018


​These questions are not a normal part of the discussion between patients
and doctors, as patients have been taught by society, their doctors, their
culture...fill in the blank as suits...that they must simply present
themselves to the doctor.  Their expectations may well be that the
clerk/receptionist who usually asks the patient what his complaint is will
convey that to the doctor along with any medical history.  The patient
likely thinks that a referring doctor has spoken with the doctor, and they
have a common plan of action.  The patient has also learned that the
physician's time is more important than their own, so may be hesitant to
repeat the info from his record, or even expand upon the complaint which
brought him in.  Rarely does the patient understand what information the
doctor has available to him, not does he question the assumptions that the
doctor makes.  Simple language differences may be a challenge between the
pair, as will the anxiety that the patient brings.

Naturally, the simplest things might be helpful, even providing the patient
some of the above mentioned tools in advance of the scheduled appointment.
He could be asked to note what improves his situation or makes it worse.
He could be advised to bring in his medications, and to record his
frequency of the use of them, and be asked to explain what each medication
is, why it was prescribed, how long he has been taking it, etc, etc.

He could be given his record to review before seeing the doctor, and asked
to note if it is correct and if there are omissions from the record.

But it is the simple act of showing the patient that he is welcome to
discuss his issues with the doctor, and in his own manner of speaking that
will help shift this into a more mutually responsible relationship with the
two parties.  Just asking, "Do you have any questions?" is not as effective
as saying, "Would you tell me in your own words what you understand about
this health issue?".

Sincerely,
Peggy Zuckerman


Peggy Zuckerman
www.peggyRCC.com

On Thu, May 31, 2018 at 1:55 PM, Nelson Toussaint <ntoussaint at tamarac.com>
wrote:

> 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
>
> ntoussaint at tamarac.com
>
>
>
> *From:* Samuel, Rana [mailto:Rana.Samuel at VA.GOV <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
> <https://maps.google.com/?q=3495+Bailey+Avenue,+Buffalo,+NY+14215+Ph:+716&entry=gmail&source=g>
>
> Ph:
> <https://maps.google.com/?q=3495+Bailey+Avenue,+Buffalo,+NY+14215+Ph:+716&entry=gmail&source=g>
> 716
> <https://maps.google.com/?q=3495+Bailey+Avenue,+Buffalo,+NY+14215+Ph:+716&entry=gmail&source=g>
> -862-8701
>
> Fax:  716-862-7824
>
> Rana.samuel at va.gov
>
>
>
>
>
> *From:* Peggy Zuckerman [mailto:peggyzuckerman at GMAIL.COM
> <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:
> http://www.improvediagnosis.org/
>
>
>
>
> ------------------------------
>
>
>
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>
>
>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>
>
> ------------------------------
>
>
>
> To unsubscribe from IMPROVEDX: click the following link:
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?
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> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>
>
>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>
> ------------------------------
>
>
> To unsubscribe from IMPROVEDX: click the following link:
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?
> SUBED1=IMPROVEDX&A=1 or send email to: IMPROVEDX-SIGNOFF-REQUEST@
> LIST.IMPROVEDIAGNOSIS.ORG
>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>






Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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