[EXTERNAL] Re: [IMPROVEDX] DX measures

Jain, Bimal P.,M.D. BJAIN at PARTNERS.ORG
Wed Feb 6 12:13:46 UTC 2019


I agree it is important to be clear about meaning of words “ diagnosis “, “ hypothesis “ and “ differential diagnosis “.
Diagnosis appears to be used in two senses, as a process when we perform diagnosis and as a result when we have made a diagnosis.
Hypothesis or more correctly, a diagnostic hypothesis refers to the status of a suspected disease which is that of an assumption which may or may not be correct. This is consistent with the definition of hypothesis in science and mathematics.
Differential diagnosis refers to a list of suspected diseases which are diagnostic hypotheses.
Diagnosis is scientific in nature as I have argued in my attached paper published in Diagnosis in 2016.

Bimal

Bimal Jain MD
Northshore Medical Center
Lynn MA 01907.

From: Peter Loa <peterloa at GMAIL.COM>
Sent: Tuesday, February 05, 2019 5:34 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] [EXTERNAL] Re: [IMPROVEDX] DX measures


        External Email - Use Caution
I agree with Robert that this discussion about "differential diagnosis" versus "hypothesis" is more than quibbling over semantics.

I do not think we fully appreciate the gravity of the word "diagnosis". Many professions avoid using the word "diagnosis" to avoid being seen as practising medicine. Even a passing remark by a doctor may be interpreted as a "diagnosis" causing much confusion afterwards. State-based licensing statues may include the word "diagnosis" creating significant legal implications we may not fully appreciate in this group.
 - "practice of medicine,” in part, by using such words as diagnosis, treatment, prevention, cure, and prescribe, in connection with disease, injury, and mental or physical condition (https://journalofethics.ama-assn.org/article/licensure-complementary-and-alternative-practitioners/2011-06)

Could be that we also do not fully understand the complexities around the word "differential" as well? Differential has multiple specific meanings which are at odds with the general concept/feeling of "hypothesis". A differential in a car, for example, changes gears, increasing the speed of the car. A differential is used to compare distinctive features between groups. A differential in maths changes function.
So I wonder when we document "differential diagnosis" in our notes, the misunderstanding from the general public and legal implications have led to the increasing hesitancy and the reduction in documented differentials over time?

Peter - medical education registrar Mackay

On Wed, 30 Jan 2019 at 15:25, Lyn Behnke <lynbehnke at gmail.com<mailto:lynbehnke at gmail.com>> wrote:
I have done that for years and the reason is exactly what you mentioned.  A beloved mentor who was both a physician and attorney told me to do that because if I fall over dead tomorrow, the next person can pick up my note, see what I saw, know what I was thinking and continue in the process or change the plan.  This was when the focus was on a longitudinal relationship in primary care.

From: Seiji Hayashi <seiji.hayashi at NPC.HUMANDX.ORG<mailto:seiji.hayashi at NPC.HUMANDX.ORG>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Seiji Hayashi <seiji.hayashi at NPC.HUMANDX.ORG<mailto:seiji.hayashi at NPC.HUMANDX.ORG>>
Date: Tuesday, January 29, 2019 at 10:41 AM
To: <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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.
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
www.isabelhealthcare.com<https://urldefense.proofpoint.com/v2/url?u=https-3A__na01.safelinks.protection.outlook.com_-3Furl-3Dhttp-253A-252F-252Fwww.isabelhealthcare.com-252F-26data-3D02-257C01-257Clisa.sanders-2540yale.edu-257Cfe876ee781744f85d84b08d65b88f4cd-257Cdd8cbebb21394df8b4114e3e87abeb5c-257C0-257C0-257C636797042785465062-26sdata-3D3gJPfS8jaQ6gcksJ6aiQFQ5i1hEa5QuWv0Q-252FnSoMC8c-253D-26reserved-3D0&d=DwMGaQ&c=vq5m7Kktb9l80A_wDJ5D-g&r=OdFSWyd_9B_X_P7v0350Bl1aeyp7F5zA-lXlf2CKjKY&m=KrqXFh0vaNpp4vZ8XEFV9Lih-dNw56ru69LkUUOirJg&s=w-Onp_UODys-R1hL9PainIePsDFSuTiCV2ByuxO1yr4&e=>


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