Debiasing

Elias Peter pheski69 at GMAIL.COM
Thu May 31 23:20:01 UTC 2018


I spent a number of years teaching Family Medicine residents (and medical students when they rotated through the local residency where I taught).  I tried to teach residents about this and considered it one of the most important lessons I could offer - much more important than the right test to order or the best dose of furosemide.

Here is my blog post <http://petereliasmd.com/node/10> about it from 2013:  Peter Elias

> Throughout our medical training we are told again and again that the most important task is an accurate diagnosis. And we hear it at CME lectures and read it in journals. An accurate diagnosis is certainly essential if one wants to offer successful and safe treatment.  But it is not enough to ask and answer: “What is the diagnosis?”
> 
> There are several other questions that every experienced clinician asks - and answers - with every visit. Or should ask. We skip these questions at considerable risk to our patients.
> 
> How sure am I of the diagnosis? 
> What data have I discarded or discounted to be this sure? (The question is not whether or not one has discarded information, it is how much and how appropriately.)
> How will I know my diagnosis is right?
> What else could it be? (What is Plan B? Plan C? Plan…X?)
> Do I need to actively consider other choices now, or can I wait?
> What do I look for to alert me that I am wrong? (This is not the same questions as how will I know I am right? Framing is important. If I am only looking for confirmation, I will only find confirmation.)
> If you are a clinician – make sure you are asking yourself these questions. It may save your patient’s life. If you are a patient – ask your clinician these questions. It may save your life.
> 
> 


Peter Elias


On 2018.05.31, at 6:17 PM, Peggy Zuckerman <peggyzuckerman at GMAIL.COM> wrote:

​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 <http://www.peggyrcc.com/>

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

From: Samuel, Rana [mailto:Rana.Samuel at VA.GOV <mailto:Rana.Samuel at VA.GOV>] 
Sent: Wednesday, May 30, 2018 12:11 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto: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 <mailto:Rana.samuel at va.gov>
 

 

From: Peggy Zuckerman [mailto:peggyzuckerman at GMAIL.COM <mailto:peggyzuckerman at GMAIL.COM>] 
Sent: Wednesday, May 30, 2018 12:59 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto: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 <http://www.peggyrcc.com/>
 

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

<image001.jpg>

 


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