semantics

Thomas Westover twest54973 at YAHOO.COM
Tue Jan 29 15:44:34 UTC 2019


Agreeeeeed but.....

Perception and semantics are also CRITICALLY important.

If one believes that the prelim (or presumed  or working or admitting) dx is “THE” dx , then one is less likely to re-examine the accuracy of the initial assumption as more data points evolve over time 

That’s why the “sloppy and paste” mentality of the EMR carries incorrect dx forward and then permanently embeds them in the chart 

Tom Westover MD 
Asst Prof 
Cooper Medical School, NJ

Sent from my iPhone

> On Jan 29, 2019, at 8:58 AM, Jarrett, Mark P <MJarrett at northwell.edu> wrote:
> 
> I think we worry sometimes too much about the terminology – hypothesis vs. differential diagnosis. The critical element is thinking beyond the primary diagnosis so that re-evaluation occurs as new data returns – not trying to make it fit the primary diagnosis only.
>  
> Mark
>  
>  
> Mark Jarrett, MD, MBA, MS
> SVP & Chief Quality Officer
> Associate Chief Medical Officer
> Northwell Health
> Professor of Medicine
> Zucker School of Medicine at Hofstra/Northwell
> (O): 516-321-6044
> (C): 917-796-3935
> mjarrett at northwell.edu
>  
>  
>  
> From: Peter Loa <peterloa at GMAIL.COM>
> Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Peter Loa <peterloa at GMAIL.COM>
> Date: Monday, January 28, 2019 at 11:36 PM
> To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> Subject: Re: [IMPROVEDX] [EXTERNAL] Re: [IMPROVEDX] DX measures
>  
> External Email. Use Caution.
> 
> Maybe this discussion about differential is problematic.
> This NEJM article argues that we should be moving towards writing hypothesis into the notes (pdf also attached) - https://www.nejm.org/doi/pdf/10.1056/NEJMp1606402
> I know I would be uncomfortable writing only hypothesis in the case notes but maybe after writing down the primary diagnosis, other differentials could be written as hypotheses?
>  
> Has anyone actually seen hypothesis written in the notes? 
> What could be the problems in you see?
>  
> Peter
> Med ed reg - Mackay
>  
> On Mon, 10 Dec 2018 at 03:30, Jarrett, Mark P <MJarrett at northwell.edu> wrote:
> It is not about a grade or being right or wrong. The problem centers around critical thinking and reassessment. It is true that the ED diagnosis is very symptom based. These symptoms are still important as test data returns. What is needed is an iterative process that incorporates new information but does not reflect earlier information. My comment on natural language processing was centered on using the documented critical thinking by the ED physician to assess if their differential diagnosis was appropriate, the admitting physician also reevaluated and subsequent providers reassessed. My fear is that checklist rich EHR has  suppressed what was on paper in the past (but not often enough).
>  
> Mark
>  
>  
> Mark P. Jarrett, MD, MBA, MS
> SVP & Chief Quality Officer
> Associate Chief Medical Officer
> Northwell Health
> Professor of Medicine 
> Zucker School of Medicine at Hofstra/Northwell
> (P) 516-321-6044
> (C) 917-796-3935
> mjarrett at northwell.edu
>  
>  
>  
> From: "Sanders, Lisa" <lisa.sanders at YALE.EDU>
> Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, "Sanders, Lisa" <lisa.sanders at YALE.EDU>
> Date: Saturday, December 8, 2018 at 2:38 PM
> To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> Subject: [EXTERNAL] Re: [IMPROVEDX] DX measures
>  
> External Email. Use Caution.
> 
> Emergency physicians make the admitting diagnosis. That’s how they are admitted but not necessarily what the doctors caring for them think. Perhaps the admission H and P should be the start point. I’m not sure that ER physicians or medicine should be graded on the admitting dx.
>  
> From: Jason Maude <jason.maude at ISABELHEALTHCARE.COM> 
> Sent: Thursday, December 06, 2018 6:07 AM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: [IMPROVEDX] DX measures
>  
> This is a very interesting study (freely available) looking at the degree of match between the admission diagnosis and what the authors call the exit diagnosis.
>  
> “Our results show that only the 21.67% of cases are identified correctly on admission….”
>  
> Could this be used as a measure for diagnosis quality in hospitals? I am sure there will be concerns about the admitting diagnosis and clinicians being rushed to put something down without enough time but the ratio between the 2 diagnoses for an institution as a whole should be a useful indicator as would the trend over time. If the measure drove institutions to focus of getting the admitting diagnosis more accurate then that would be good.
>  
> This should also be practical to produce as would not involve the clinicians in any additional work.
>  
> In an earlier discussion, I asked if there were any measures that were practical, where there were no concerns and that we could all support but got replies. I really feel that if we are to get diagnosis the respect it deserves from hospitals and health systems then we need a measure. We have all been talking about this for a long time, but I do not sense we are any further forward!
>  
> Regards
>  
> Jason Maude
> Founder and CEO Isabel Healthcare
> Tel: +44 1428 644886
> Tel: +1 703 879 1890
> www.isabelhealthcare.com
>  
>  
> 
> 
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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