[External] [IMPROVEDX] Recent articles of note

Mark Gusack gusackm at COMCAST.NET
Thu Oct 4 16:58:57 UTC 2018


Good Afternoon Everyone:

 

I enjoyed Gordy’s article.  However, I’m retired from the VA, so wasn’t able to gain access to David’s article which, I’m sure is also valuable.  I agree completely with John’s position in his email below.  However, I would like to comment on the most important statement he makes at the end:

 

“Knowing which diagnoses on the list are serious considerations.”

 

I am in complete agreement with this statement and wish to expand upon it.  This is a factor that can be dealt with through the modification of diagnosis lists via risk assessment and prioritization.  So, right after my residency, I started to build up my own diagnosis lists.  And, I have to say, during my almost forty years in pathology I was routinely laughed at and disparaged for these lists by my fellow pathologists.  Yet, I was never sued.  Although I can’t prove it, I think my lists went far in protecting the patient from harm and me from an experience far worse than being ostracized by my colleagues.  Did I ever make a mistake?  Yes.  However, they were virtually always identified and rectified prior to the issuance of a report and those that weren’t were rare and clinically insignificant and here’s why.  In addition to building checklists, I also began to prioritize those lists based on:

 

*	False Negative Risks – Adverse outcomes for failing to make a diagnosis
*	False Positive Risks – Adverse outcomes for making the wrong diagnosis

 

That is, I made sure that diagnoses with significant potential impact on the patient would be handled differently.  This included one or more of the following:

 

*	Delaying reporting allowing me to take a second look to make sure I hadn’t committed closure bias
*	Referring to notebooks I had set up containing key articles regarding diagnostic criteria to recalibrate
*	Referring to glass slides and Kodachromes of prior confirmed cases for the same purpose
*	Showing slides to another pathologist to obtain an immediate second opinion forcing me to justify my diagnosis
*	When appropriate, consulting with an expert at another institution

 

It is my position that this type of approach should be applied across all medical diagnostic fields as follows: 

 

*	Delineating all potential diagnoses associated with a set of clinical signs and symptoms
*	Determining and ranking risks for false positive and false negative diagnoses
*	Considering the epidemiology and so, probability of a diagnosis being present
*	Adjusting the depth of the diagnostic workup to match these risks employing the actions I took above listed above

 

This would go far in Reducing Diagnostic Error in Medicine

 

Hope everyone’s week has gone well.

 

Mark Gusack, M.D.

President

MANX Enterprises, Ltd.

304 521-1980

 

From: Ely, John <john-ely at UIOWA.EDU> 
Sent: Thursday, October 4, 2018 8:59 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] [External] [IMPROVEDX] Recent articles of note

 

Two great articles from Gordy Schiff and David Newman-Toker.  Gordy says we should communicate honestly about uncertainty, but the medical profession has strong cultural norms against this.  David says we should reach for the low hanging fruit, but the lowest of the low is to target the most common cause of diagnostic errors, which was not mentioned in either article.  The most common cause of diagnostic errors is the failure to consider the correct diagnosis as a possibility. (1,2)  It never gets on the radar screen.  Reviewing a differential diagnosis checklist, preferably in the presence of the patient, could force us to consider the correct diagnosis.  We still need knowledge and experience to know which diagnoses on the list are reasonable possibilities and which should be ruled out before the patient leaves.  We can maintain our cultural norms by first stating what we think the patient has before reviewing the differential diagnosis.  Stating what we think reassures the patient that we’re not completely in the dark.  Reviewing the differential diagnosis reassures the patient that we are being thorough, and avoids the need for the patient to ask “What else could this be?”  (which is our job, not theirs)  Reviewing a diagnostic checklist is Pat Croskerry (de-biasing).  Knowing which diagnoses on the list are serious considerations is Geoff Norman (knowledge and experience).

 

1.            Schiff GD, Hasan O, Kim S, Abrams R, Cosby K, Lambert BL, et al. Diagnostic error in medicine: analysis of 583 physician-reported errors. Arch Intern Med. 2009;169(20):1881-7.

 

2.            Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-9.

 

John W. Ely, MD

University of Iowa

 

 

 

 

 

From: mgraber [mailto:graber.mark at GMAIL.COM] 
Sent: Wednesday, October 03, 2018 5:17 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG> 
Subject: [External] [IMPROVEDX] Recent articles of note

 

FYI -  Two significant articles just published …..

 

Ten Principles for More Conservative, Care-Full Diagnosis

http://annals.org/aim/article-abstract/2705208/ten-principles-more-conservative-care-full-diagnosis

 

Where Is the “Low-Hanging Fruit” in Diagnostic Quality and Safety?

https://journals.lww.com/qmhcjournal/Citation/2018/10000/Where_Is_the__Low_Hanging_Fruit__in_Diagnostic.9.aspx

 

 

 

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 to Improve Diagnosis in Medicine


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