Errors in diagnosis and a possible way forward.

Peter Loa peterloa at GMAIL.COM
Wed Nov 28 21:37:20 UTC 2018


"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?"

Because there are serious medico-legal and clinical consequences for
thinking out loud in the notes even though it would be safer and better for
patients in the longer term.
Non-clinicans don't understand the dynamics of turfing as well. Medicine is
not a 100% noble and there is a lot of gaming of work when people are
salaried -
https://journalofethics.ama-assn.org/article/turfing-revisited/2012-05

Peter
- from bushfire Australia

On Thu, 29 Nov 2018 at 06:13, Jason Maude <jason.maude at isabelhealthcare.com>
wrote:

> 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?
>
>
>
>
>
> Jason Maude
>
> Founder and CEO Isabel Healthcare
> Tel: +44 1428 644886
> Tel: +1 703 879 1890
> www.isabelhealthcare.com
>
>
>
>
>
> *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.
>
>
>
> Tom,
>
> 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.
>
> Joe
>
>
> Sent from my iPhone
>
>
> On Nov 28, 2018, at 08:17, Thomas Westover <
> 000000040134e744-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG> wrote:
>
> Jason
>
>
>
> 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....)
>
>
>
> Respectfully
>
> Tom
>
>
>
> Thomas Westover MD
>
>
>
>
>
>
>
> On Wednesday, November 28, 2018, 8:20:47 AM EST, Jason Maude <
> jason.maude at ISABELHEALTHCARE.COM> wrote:
>
>
>
>
>
> Rob
>
> 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!
>
>
>
> Regards
>
> Jason
>
>
>
> *From: *Robert Bell <
> 0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>
> *Reply-To: *Society to Improve Diagnosis in Medicine <
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Robert Bell <rmsbell200 at YAHOO.COM>
> *Date: *Tuesday, 27 November 2018 at 23:13
> *To: *"IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> *Subject: *[IMPROVEDX] Errors in diagnosis and a possible way forward.
>
>
>
>
>
> Dear all
>
>
>
> 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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> Medicine
>
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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