Errors in diagnosis and a possible way forward.
jason.maude at ISABELHEALTHCARE.COM
Wed Nov 28 20:10:38 UTC 2018
But why would clinicians do this? Since clinicians often tell me they have the ddx in their head wouldn’t it take just as long to write in 3 irrelevant ones as 3 relevant ones?
Since the ddx is very useful to show what somebody was thinking, I wonder whether peer pressure wouldn’t dissuade the gamers but I agree that some management would help to set a standard and ensure it was used properly. I can see how measures that aren’t useful would be gamed but if all agree that the ddx is actually useful why would it be gamed?
There will be concerns about any measure and none will be perfect but if we don’t put our collective weight behind one then we will be having this same discussion in 10 years time!
What are the other measures that are practical and could be easily implemented where we don’t have any concerns?
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From: Joseph Keary <jgkeary at GMAIL.COM>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Joseph Keary <jgkeary at GMAIL.COM>
Date: Wednesday, 28 November 2018 at 16:03
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Errors in diagnosis and a possible way forward.
You make an excellent point about the need to avoid "click the box" templated differential dx's. I think that is one of the major objections by both providers and payers to effective utilization of the EMR. I agree that we need tools that facilitate the diagnostic process, not replace it.
Sent from my iPhone
On Nov 28, 2018, at 08:17, Thomas Westover <000000040134e744-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:000000040134e744-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>> wrote:
you bring up a good point (needing a definable measure) but be careful what measure you wish for...
we need a measure that isn't easily "gamed" (or creates simple "work arounds" that aren't useful)
eg, if the metric/measure is the creation of a "diff dx" then clinicians (or even an EMR vendor with some quick and dirty software code) could easily list 1, 2 or 3 conditions that could reflect the chief complaint but dont really reflect that particular pt's narrative story, labs and imaging
For example, an easy diff dx to list for any pt with "abdom pain" is appy, biliary colic and kidney stone. BUT those diff dx are hardly relevant for a pregnant woman with episodic crampy low abdom pain that started following a gush of water from her vagina (she's likely in labor obviously)
the metric needs to be truly relevant for the clinicians and NOT just another box to click in the EMR
the ideal measure is one that the clinician wants/needs and is helpful in decision making (I certainly acknowledge that a diff dx is a helpful and worthwhile endeavor IF it is done thoughtfully....)
Thomas Westover MD
On Wednesday, November 28, 2018, 8:20:47 AM EST, Jason Maude <jason.maude at ISABELHEALTHCARE.COM<mailto:jason.maude at ISABELHEALTHCARE.COM>> wrote:
You are still trying to address some almost insurmountable issues like a single payor system.
My view has always been that our missing final link is a measure that regulators can use. They may agree with everything we say and want to include something on diagnosis but need a measure to make it happen. We have spent too long talking about perfect measures and just need 3 (or even one!) that we can agree on and are practical. Hence my long-standing suggestion that the recording of a differential diagnosis in the notes should become a requirement. It makes clinical sense and will be easy to implement and measure if one is present or not.
This small but important measure could start to drive a huge change in behaviour.
An historical example is the abolition of the slave trade in the UK. This was finally achieved via an obscure change in legislation that removed protection for ships flying under the then neutral US flag. It meant that within 2-3 years 80% of the operators in the UK went out of business and then abolition by parliament became easy. The lesson is this seemingly small technical change achieved what 20 years of head on battling had failed to achieve!
From: Robert Bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Robert Bell <rmsbell200 at YAHOO.COM<mailto:rmsbell200 at YAHOO.COM>>
Date: Tuesday, 27 November 2018 at 23:13
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: [IMPROVEDX] Errors in diagnosis and a possible way forward.
I could be wrong but it seems that the problems relating to errors in diagnosis are so massive that any health organization/Society that tries to do something gets mired in the weeds with little eventually happening.
It would seem that that it would be good to tackle one thing at time in a significant way and succeed at something.
Also, the piece by Mike Posata is a good example of the influence of money on errors.
My top three areas for research would be:
* Supporting a single payer system, like most of the developed world already has, and investigating the benefits of a single payer system in preventing errors in diagnosis.
That would remove so many hurdles we do not need in medicine. A big challenge but collaboratively, I think, could be done.
* Identifying the very commonest errors in diagnosis in each specialty, and working hard on those to prevent them - pulmonary medicine would be my first.
* Clarifying all the issues regarding laboratory tests, including, ordering, reporting, interpretation, and subsequent action.
My basic message is to tackle something that is likely to produce results, and can be completed in a defined period of time with the available resources.
Comments very welcome.
Rob Bell, M.D.
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