[No SPF Record] [IMPROVEDX] Dhruv Khullar on overdiagnosis

Edward Winslow edbjwinslow at GMAIL.COM
Thu Nov 15 18:38:29 UTC 2018


A wise man once said:
"The plural of anecdote is not data"

Might we not be well served to discuss optimizing the process  - from H&P
through decision making (including being aware of the use of heuristics and
how Biases might influence our thought process) and use of tests to help
strengthen or weaken confidence in our conclusions.
We have already posited that including the patient in the process. Some
real data suggest this concept may actually improve our outcomes.

On Thu, Nov 15, 2018, 10:22 AM Bob Swerlick <rswerli at gmail.com wrote:

> We are weighing in all based upon what we happen to observe within our own
> bubbles. What is more significant? Overdiagnosis? Underdiagnosis? It all
> depends upon our particular experiences. In the absence of actual numbers
> which allow us to assess impact, it boils down to the "taste great" v.
> "less filling" debate.
>
> All of these are significant for those affected and unfortunately
> addressing one end of the spectrum will almost certainly aggravate the
> situation at the other end. One problem needs more sensitivity while the
> other needs more specificity of responses. The organization has benefited
> from compelling anecdote in its mobilization phase. Compelling anecdote is
> great at driving the base. However, in order to actually solve problems we
> need much more than anecdote. No matter how good we make any system, we
> will always miss the diagnosis in some cases and overdiagnose in others. We
> will always find anecdotes that MAY drive practice changes. Without
> something more quantitative we will never be able to discern whether any
> given anecdote should serve as the basis for practice change.
>
> Bob Swerlick
>
> On Thu, Nov 15, 2018 at 8:23 AM Peggy Zuckerman <peggyzuckerman at gmail.com>
> wrote:
>
>> To say that "a diagnositic error is only a problem when it leads to
>> treatment error" is a bit too broadly stated.  A treatment which follows a
>> poor diagnosis may exacerbate an underlying conditon, and certainly is
>> likely to delay the proper diagnosis.  That delay can cause an infection to
>> spread, a tumor to grow, etc.   I am in perfect agreement that an
>> overdiagnosis or medicalizing a self-limiting condition can lead to
>> inappropriate treatments.   It seems the greater risk is that of a
>> misdiagnosis which becomes a barrier to getting proper diagnosis and the
>> appropriate treatment.
>> Peggy Zuckerman
>> www.peggyRCC.com
>>
>>
>> On Wed, Nov 14, 2018 at 9:16 PM Bertrand H. Vipond <
>> Bertrand.H.Vipond at kp.org> wrote:
>>
>>> The ultimate problem is treatment error.  Diagnostic error is only a
>>> problem when it leads to treatment error.
>>>
>>> Overdiagnosis, or overmedicalizing, even if a valid diagnosis, can lead
>>> to inappropriate treatment!
>>>
>>>
>>>
>>> *From:* Rory Jaffe <rjaffe at CHPSO.ORG>
>>> *Sent:* Wednesday, November 14, 2018 9:05 AM
>>> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>>> *Subject:* Re: [IMPROVEDX] [No SPF Record] [IMPROVEDX] Dhruv Khullar on
>>> overdiagnosis
>>>
>>>
>>>
>>> *Caution: *This email came from outside Kaiser Permanente. Do not open
>>> attachments or click on links if you do not recognize the sender.
>>> ------------------------------
>>>
>>> Totally agree. In our quest to reduce diagnostic error, we must be
>>> careful not to overincentivize indiscriminate pursuit of a diagnosis. There
>>> are plenty of situations in which it is better to leave things alone.
>>>
>>>
>>>
>>> An example being that of prostate cancer diagnoses from PSA surveillance
>>> in otherwise asymptomatic men. The successful diagnosis and resulting
>>> effect on the person may be worse than the disease.
>>>
>>>
>>>
>>> Rory Jaffe, MD MBA, Executive Director, CHPSO
>>> <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.chpso.org_&d=DwMGaQ&c=ZMR5nv7DeMA_5yIzV7zEdkSfOjTGya0xwGqp1JcaTq0&r=YXAKagORvM3QHE8HlbKK5LvoafwQgRBw2-gSOaJ2JAc&m=fh7j6Be5gVVyYox8_M4bxKxPwKSihzjmR3veNC0eAno&s=IB7xUwHiYxFvVlFuMCyeDKiHb2WeeAVUk-EsyhzM7BM&e=>
>>>
>>> 1215 K Street, Suite 930
>>> Sacramento, CA 95814
>>> rjaffe at chpso.org
>>> (916) 552-2600
>>>
>>>
>>>
>>> [image: CHPSO-logo-tag-outlines]
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>>> <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.hqinstitute.org_hqi2018&d=DwMGaQ&c=ZMR5nv7DeMA_5yIzV7zEdkSfOjTGya0xwGqp1JcaTq0&r=YXAKagORvM3QHE8HlbKK5LvoafwQgRBw2-gSOaJ2JAc&m=fh7j6Be5gVVyYox8_M4bxKxPwKSihzjmR3veNC0eAno&s=-3y5LfbDiOh-JPrc17RSlNEo6rS1pTeJMwmkjnj316s&e=>
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>>>
>>> *From:* Helen Haskell <haskell.helen at GMAIL.COM>
>>> *Sent:* Wednesday, November 14, 2018 8:01 AM
>>> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>>> *Subject:* [No SPF Record] [IMPROVEDX] Dhruv Khullar on overdiagnosis
>>>
>>>
>>>
>>>
>>> https://www.nytimes.com/2018/11/06/well/live/a-profusion-of-diagnoses-thats-good-and-bad.html
>>> <https://urldefense.proofpoint.com/v2/url?u=https-3A__www.nytimes.com_2018_11_06_well_live_a-2Dprofusion-2Dof-2Ddiagnoses-2Dthats-2Dgood-2Dand-2Dbad.html&d=DwMFaQ&c=hx0HUg_nG-xRkKlwWZeJFCbvzzw0Ym5DwdL_1FKbReI&r=ykcs2wU25yxj5BckI49bSg&m=e_MZgkfPXgLkgob4dJJ980Oytg1vujFOQnxSCR4cizY&s=24RC-QQWG6WAFYqVK3X7uhyZr7yrYcfsiPmYqeFJK-8&e=>
>>>
>>>
>>>
>>> "A central problem is that medicalized diagnoses often come with
>>> medicalized treatments: Our penchant for pills outstrips even our desire
>>> for diagnosis. Since the 1990s, the number of office visits for sleep
>>> problems has doubled, and diagnoses of insomnia have increased sevenfold.
>>> But prescriptions for sleep medications have increased more than 30 times.
>>>
>>> This is perhaps most concerning for children. About 12 percent of
>>> children in America now carry a diagnosis of A.D.H.D, and there was a
>>> 40-fold increase in childhood bipolar disorder diagnoses between 1994 and
>>> 2003. Five times as many children are now prescribed psychostimulant and
>>> antipsychotic medications as were in the 1980s. Today, a quarter of
>>> children and teenagers take prescription drugs regularly, and seven percent
>>> of older adolescents and young adults report abusing opioids — most of whom
>>> were initially prescribed them by a doctor."
>>>
>>>
>>>
>>> Also Lown:
>>>
>>>
>>> https://lowninstitute.org/news/blog/when-diagnosis-becomes-dangerous-a-taxonomy-of-medicalization/
>>> <https://urldefense.proofpoint.com/v2/url?u=https-3A__lowninstitute.org_news_blog_when-2Ddiagnosis-2Dbecomes-2Ddangerous-2Da-2Dtaxonomy-2Dof-2Dmedicalization_&d=DwMFaQ&c=hx0HUg_nG-xRkKlwWZeJFCbvzzw0Ym5DwdL_1FKbReI&r=ykcs2wU25yxj5BckI49bSg&m=e_MZgkfPXgLkgob4dJJ980Oytg1vujFOQnxSCR4cizY&s=ZrLQMdTQ-2L8sb8xDckAmdcaZHijDIC5fBAYLoLHkKA&e=>
>>>
>>>
>>> "More newly recognized diagnoses is not inherently a good or bad thing.
>>> But we need to look deeper at this pattern – who is creating these
>>> diagnoses, who they are affecting, and how they are treated – to better
>>> understand how some diagnoses can be helpful and others harmful."
>>>
>>>
>>>
>>>
>>>
>>>
>>> ------------------------------
>>>
>>>
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>>
>>
>> ------------------------------
>>
>>
>> To unsubscribe from IMPROVEDX: click the following link:
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>> 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/
>
>
>
> --
> Bob Swerlick
>
> ------------------------------
>
>
> 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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