[EXTERNAL] Re: [IMPROVEDX] [No SPF Record] [IMPROVEDX] Culture

Andrew Olson olso5714 at UMN.EDU
Mon Jun 18 02:53:04 UTC 2018


This is a valuable discussion that gets to the heart of much of what we
do.  I think as we discuss arrogance/overconfidence and intellectual
humility we should think about these as products of the systems in which we
learn and practice rather than personal traits, and thus it is easier to be
less defensive.

Physician training in the US primarily occurs in an open loop system, where
we generally do not know the downstream consequences of our decisions.  It
is human nature that we consider unknown outcomes to be positive (no news
is good news) and thus we all just think we are very good at diagnostic
decision-making since we receive little effective or timely feedback.

Take, for example, if you played golf but only hit a drive on each hole and
then someone else on the team took over to finish each hole. You assume
that they will tell you if your ball was a great shot or went in the rough,
but it turns out that the system doesn't encourage that; you still hold
that assumption.  Thus, since there is no drive-related feedback, we would
all come to quickly believe that we are better than we are.

This seems ridiculous, but mirrors closely the system we have in medicine
and medical education today.  It is fundamental that we build systems to
ensure we know the outcomes of our decisions.

On Fri, Jun 15, 2018 at 8:39 AM, Grefe, Rosemary <
RGrefe at childrensnational.org> wrote:

> No,  I have attached a summation of the study that I am referring to.
>
>
>
> *From:* Tom Benzoni [mailto:benzonit at GMAIL.COM]
> *Sent:* Thursday, June 14, 2018 8:26 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* [EXTERNAL] Re: [IMPROVEDX] [No SPF Record] [IMPROVEDX] Culture
>
>
>
> ATTENTION: External Email! Do not click attachments/links unless sender is
> known.
> ------------------------------
>
> https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1731967
> <https://urldefense.proofpoint.com/v2/url?u=https-3A__jamanetwork.com_journals_jamainternalmedicine_fullarticle_1731967&d=DwMFaQ&c=Zoipt4Nmcnjorr_6TBHi1A&r=iMpVRgI4Jb8qPZsZHXUj0g&m=A8yt_8zuAdOoCYOTkAPV5uooOtZKYKBDp6hLmtZ9Qgw&s=I0LqetjOjuhBykUNvo57ymTJ2pTt6G-jREMpk0h04wk&e=>
>
>
>
> Is this the study to which you refer?
>
> tom
>
>
>
>
>
> On Thu, Jun 14, 2018 at 2:05 PM NANCY GENN <nancy.genn at comcast.net> wrote:
>
> There was a study, either Harvard or Johns Hopkins, contrasting PCP's and
> specialists, along 2 variables, diagnostic accuracy and diagnostic
> certainty.   Although specialists had a greater degree of accuracy than
> PCP's, their error rate was still measured very high (I remember it being
> about 17%), but they were astoundingly certain that their diagnosis had
> been correct and rejected  the notion that they needed either further
> objective testing or another opinion (70%).  The interpretation of the
> researchers was that it was arrogance that contributed to the high rate of
> diagnostic error.  It was about 5 years ago.  If I find it, I'll send you
> the citation.
>
>
>
> Nancy Genn
>
> On June 14, 2018 at 12:51 PM ROBERT M BELL <0000000296e45ec4-dmarc-
> request at LIST.IMPROVEDIAGNOSIS.ORG> wrote:
>
> Thanks Tom and Bob,
>
>
>
> Is that the the lack of caution that comes with any degree of arrogance?
>
>
>
> Does arrogance itself have a role in diagnostic error?
>
>
>
> Has that ever been studied?
>
>
>
> Does anyone know?
>
>
>
> Rob Bell
>
>
>
>
>
>
>
>
>
> On Jun 13, 2018, at 8:52 PM, Tom Benzoni <benzonit at GMAIL.COM> wrote:
>
>
>
> From 35+ years in the front lines of health care, this is for sure so.
>
> And the arc is increasing.
>
> I've recently moved from an area that always felt a bit inadequate to one
> that is self-assured.
>
> The prior was much safer than the latter.
>
> Ever hear the phrase "Fat, dumb and happy?"
>
>
>
> tom benzoni
>
>
>
> On Tue, Jun 12, 2018 at 12:26 PM Bob Latino <blatino at reliability.com>
> wrote:
>
> While this is referencing the Oil & Gas industry, there are some
> interesting stats related to the 'zero commitments' we were talking about
> earlier.
>
>
>
> "Unsurpirsingly, there is even a correlation between committing to a ‘zero
> accident’ vision on a project and killing more people. In a thoughtful
> recent study, British colleagues have demonstrated that projects subject to
> a ‘zero safety’ policy or program actually slightly increase the likelihood
> of having a serious life-changing accident or fatality (Sheratt & Dainty,
> 2017)."
>
>
>
> Just an FYI.
>
>
>
> http://www.safetydifferently.com/oil-and-gas-safety-in-a-
> post-truth-world/#comment-3802
> <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.safetydifferently.com_oil-2Dand-2Dgas-2Dsafety-2Din-2Da-2Dpost-2Dtruth-2Dworld_-23comment-2D3802&d=DwMFaQ&c=Zoipt4Nmcnjorr_6TBHi1A&r=iMpVRgI4Jb8qPZsZHXUj0g&m=A8yt_8zuAdOoCYOTkAPV5uooOtZKYKBDp6hLmtZ9Qgw&s=LzE7bFvl0m-4xp0DTbBt6K-Sd1BSveeYSBvV-WQgo8g&e=>
>
>
>
> *Robert J. Latino, CEO*
>
> Reliability Center, Inc.
>
> 1.800.457.0645
>
> blatino at reliability.com
>
> www.reliability.com
> <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.reliability.com_&d=DwMFaQ&c=Zoipt4Nmcnjorr_6TBHi1A&r=iMpVRgI4Jb8qPZsZHXUj0g&m=A8yt_8zuAdOoCYOTkAPV5uooOtZKYKBDp6hLmtZ9Qgw&s=s4ZisNB7ZIdiDNqZD7xVCvGpv4Lwkj9cnU2iERVQjWo&e=>
>
>
>
>
>
> *From:* Mark Graber [mailto:Mark.Graber at Improvediagnosis.org]
> *Sent:* Tuesday, June 12, 2018 11:07 AM
> *To:* Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.
> IMPROVEDIAGNOSIS.ORG>; Bob Latino <blatino at reliability.com>
> *Subject:* Re: [IMPROVEDX] [No SPF Record] [IMPROVEDX] Culture
>
>
>
> That Decker article on ‘getting to zero’ is amazing – thanks for
> forwarding it Bob.
>
>
> It was exactly this question, can we get to zero, that prompted my
> first-ever paper on diagnostic errors, arising from assertions at national
> meetings that we could completely eliminate serious safety events.   Don
> Berwick had it right: “The search for zero error rates is doomed from the
> start”.
>
>
>
> Its also the wrong question; Better questions are:  How can we make
> progress, and how can we measure that?  And… now with the knowledge that
> unintended consequences will accompany whatever we do, how do we minimize
> those while maximizing accuracy, timeliness, and safety?
>
>
>
> Mark
>
>
>
> Mark L Graber MD FACP
>
> President, SIDM
>
> Senior Fellow, RTI International
>
> Professor Emeritus, Stony Brook University
>
>
>
>
>
>
>
>
>
> *From: *Bob Latino <blatino at RELIABILITY.COM>
> *Reply-To: *Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Bob
> Latino <blatino at RELIABILITY.COM>
> *Date: *Tuesday, June 12, 2018 at 10:03 AM
> *To: *Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> *Subject: *Re: [IMPROVEDX] [No SPF Record] [IMPROVEDX] Culture
>
>
>
> Along this thread I thought this article may be of interest.  Declarations
> of 'zero' metrics, often has unintended consequences.  While on the surface
> they seem logical and admirable, they can suppress feedback loops for fear
> of affecting the zero metric (such as zero harm).
>
>
>
> The article is authored by noted safety researcher Sidney Dekker.
>
>
>
> Does this 'zero' mentality fall into the realm of how success in reducing
> Dx error is measured?  Is it applicable?
>
>
>
> Regards
>
> Bob Latino
>
>
>
> *Robert J. Latino, CEO*
>
> Reliability Center, Inc.
>
> 1.800.457.0645
>
> blatino at reliability.com
>
> www.reliability.com
> <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.reliability.com_&d=DwMFaQ&c=Zoipt4Nmcnjorr_6TBHi1A&r=iMpVRgI4Jb8qPZsZHXUj0g&m=A8yt_8zuAdOoCYOTkAPV5uooOtZKYKBDp6hLmtZ9Qgw&s=s4ZisNB7ZIdiDNqZD7xVCvGpv4Lwkj9cnU2iERVQjWo&e=>
>
>
>
>
>
> *From:* Rory Jaffe [mailto:rjaffe at CHPSO.ORG <rjaffe at CHPSO.ORG>]
> *Sent:* Monday, June 11, 2018 3:04 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] [No SPF Record] [IMPROVEDX] Culture
>
>
>
> The other studies show a reasonably strong link.
>
>
>
> Some of the problems in making an overall assessment is that culture is
> very local, varying broadly from department to department within an
> organization. Within-organization variability is generally much higher than
> between-organization vulnerability on safety culture surveys. So studies
> that look at “culture” in the organization as a whole tend to have weaker
> results. The specific papers do show a decent link.
>
>
>
> Also backing this conclusion is that, in other industries, this has been
> studied and there is a definite link between culture and safety.
>
>
>
> I think there is a consensus in health care that there’s a link. Look at
> “to err is human” and subsequent publications from the National Academy of
> Medicine. These publications strongly presume that culture is important
> driver of safety.
>
>
>
>
>
> *From:* ROBERT M BELL <rmsbell200 at yahoo.com>
> *Sent:* Monday, June 11, 2018 10:47 AM
> *To:* Society to Improve Diagnosis in Medicine <IMPROVEDX at list.
> improvediagnosis.org>; Rory Jaffe <rjaffe at chpso.org>
> *Subject:* Re: [No SPF Record] [IMPROVEDX] Culture
>
>
>
> Thanks Rory Jaffe,
>
>
>
> Very kind.
>
>
>
> Do you yourself have an overall opinion? I looked at the Weaver article
> which evaluated many studies. and, from my limited interpretation, that did
> not seem too positive.
>
>
>
> Is there a general consensus amongst the medical profession as to whether
> culture is important in preventing errors?
>
>
>
> Is to ERR more resistant to intervention than we think?
>
>
>
> Rob Bell
>
>
>
>
>
> On Jun 11, 2018, at 9:58 AM, Rory Jaffe <rjaffe at chpso.org> wrote:
>
>
>
> Weaver SJ, Lubomksi LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM. Promoting
> a culture of safety as a patient safety strategy: a systematic review. *Ann
> Intern Med*. 2013;158(5 Pt 2):369-374. doi:10.7326/0003-4819-158-5-
> 201303051-00002.
>
>
>
>
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-- 
Andrew P.J. Olson, MD, FACP, FAAP
Assistant Professor
Director, Medical Educator Scholarship and Development
Director, Becoming a Doctor Course
Departments of Medicine & Pediatrics
University of Minnesota Medical School

Office: 612-625-2290
Pager: 612-899-2999
Fax: 612-624-3189






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


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