[EXTERNAL] Re: [IMPROVEDX] DX measures

Swerlick, Robert A rswerli at EMORY.EDU
Tue Jan 29 16:26:00 UTC 2019


I think this discussion is more than quibbling over semantics. In my opinion, it cuts right to the purpose of the Society and what improved diagnoses actually means. A diagnoses is not really a "thing" to get right or wrong. I agree that a given diagnosis represents a hypothesis or perhaps a grouping of hypotheses about what the future will bring.

A given diagnoses may suggest a natural history that may be variable. Even a single diagnosis may imply many different futures for a given patient. Thus, you may get the diagnosis right but still have great uncertainty about the future.

I maintain that the power of being able to diagnose is all about making predictions. The Society is currently named based upon the desire to improve diagnoses. Substitute the terms hypothesis (improved hypotheses) or prediction (improved prediction) and I think it changes one's perspective. I see one of the issues that has faced the SIDM is we have lumped all types of diagnoses (predictions) together. Some of the predictions focus on predictive time frames in the minutes to hours range while other focus on predictive time frames in years to decades.

One always needs to set different expectations for the accuracy of predictions in the near term v. predictions in the far term. Phillip Tetlock in his book "Superforecasting" describes the creation of the Good Judgement Project  and the identification of specific individuals who are very good at forecasting.

https://www.amazon.com/Superforecasting-Science-Prediction-Philip-Tetlock/dp/0804136718

The best forecasters will not make forecasts that attempt to project far into the future.  I believe his work is very relevant this discussion. It may be useful to consistently translate diagnoses in hypotheses and explicitly acknowledge the time frames implied by the hypotheses (predictions).  The more extended the time frame, the more uncertainty we should accept and expect.

The SIDM may find this framework useful for tackling different sets of diagnostic problems.  For example,  assessing someone with chest pain or a headache with the concern of a brewing catastrophic MI or stroke which may play out over the next minutes or hours is practically and conceptually very different from assessing the risks of early possible malignancies observed in tissue by anatomic pathology methods.   Those events may play out decades in the future and I believe that no one should expect to be able to consistently predict specific events in those time frames. Yet, we have tended to lump how we approach all diagnoses (and mis-diagnoses) together.

Bob

Robert A. Swerlick, MD
Alicia Leizman Stonecipher Chair of Dermatology
Professor and Chairman, Department of Dermatology
Emory University School of Medicine
404-727-3669

________________________________
From: Seiji Hayashi <seiji.hayashi at NPC.HUMANDX.ORG>
Sent: Tuesday, January 29, 2019 8:47 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] [EXTERNAL] Re: [IMPROVEDX] DX measures

I've been writing my differential diagnosis in the notes section of the Assessment to help my thinking as well as those who may read it later. It's my form of doing a "diagnostic time out" to make sure I'm not missing anything. Some have argued that this increases liability, but after talking with physicians and those in liability, considering something but ruling it out is less of a risk because you thought about it and acted in the best interest of the patient (even if you were wrong). This removes the argument that you were negligent, and a peer reviewer may agree that the thought process is reasonable.

In addition, if your practice routinely shares medical records with patients, this differential enables the patient to understand the care process better.

I'm sure others have their own experiences.
[https://mailfoogae.appspot.com/t?sender=ac2VpamkuaGF5YXNoaUBucGMuaHVtYW5keC5vcmc%3D&type=zerocontent&guid=d02f097b-4a26-480b-9f75-2ce21f659526]ᐧ

On Mon, Jan 28, 2019 at 11:36 PM Peter Loa <peterloa at gmail.com<mailto:peterloa at gmail.com>> wrote:
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<mailto: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<mailto:mjarrett at northwell.edu>







From: "Sanders, Lisa" <lisa.sanders at YALE.EDU<mailto:lisa.sanders at YALE.EDU>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, "Sanders, Lisa" <lisa.sanders at YALE.EDU<mailto:lisa.sanders at YALE.EDU>>
Date: Saturday, December 8, 2018 at 2:38 PM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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<mailto:jason.maude at ISABELHEALTHCARE.COM>>
Sent: Thursday, December 06, 2018 6:07 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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
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