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

Tom Benzoni benzonit at GMAIL.COM
Mon Jun 18 14:40:54 UTC 2018


Andrew:
You describe a recent phenomenon, the open loop method.
This is an artifact of Electronic Billing Records, EMR's in common (but
incorrect) parlance.
In the days of paper charts (to which I am not advocating return) I would
end my dictation with a certain phrase if I was uncertain or just curious
as to the outcome. When the chart came back to me for ink signature, I'd
look at the line at the end and, if a key phrase was there, I'd sit down,
read and learn.
Now I have to have all charts closed and billed before leaving campus.
People who have no idea what we do tell me they monitor every mouse click
to ensure I/we don't open any charts under threat of report to the State.
I have no iterative learning opportunity.

There are better ways and we'd better find them. Learning at the point of
saying "I'm ignorant" is the best learning of them all.

tom


On Sun, Jun 17, 2018 at 9:59 PM Andrew Olson <olso5714 at umn.edu> wrote:

> 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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>> Medicine
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>> <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FINDEX&d=DwMFaQ&c=Zoipt4Nmcnjorr_6TBHi1A&r=iMpVRgI4Jb8qPZsZHXUj0g&m=A8yt_8zuAdOoCYOTkAPV5uooOtZKYKBDp6hLmtZ9Qgw&s=ZDDGufL5yjjcZRMhE83dqbPm6lfzxj2fRMtM3tfy-fg&e=>
>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
>> Medicine
>>
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/
>> <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.improvediagnosis.org_&d=DwMFaQ&c=Zoipt4Nmcnjorr_6TBHi1A&r=iMpVRgI4Jb8qPZsZHXUj0g&m=A8yt_8zuAdOoCYOTkAPV5uooOtZKYKBDp6hLmtZ9Qgw&s=_5T9DrhKQRzt5K4h7Aex0kQDKCQfZbyK4YYtQMX4T7k&e=>
>>
>>
>> ------------------------------
>>
>>
>>
>> To unsubscribe from IMPROVEDX: click the following link:
>>
>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
>> <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FSUBED1-3DIMPROVEDX-26A-3D1&d=DwMFaQ&c=Zoipt4Nmcnjorr_6TBHi1A&r=iMpVRgI4Jb8qPZsZHXUj0g&m=A8yt_8zuAdOoCYOTkAPV5uooOtZKYKBDp6hLmtZ9Qgw&s=Dt-PMr-08q889A5AIrvtiqcAem9nPVEmK2YCwM1oCSA&e=>
>>
>> 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 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/
>>
>
>
>
> --
> 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
>
> ------------------------------
>
>
> 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 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/






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


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