Kahneman interview - putting a premium on error detection

Gerrit Jager gerrit.jager at PLANET.NL
Sat Feb 9 17:02:46 UTC 2019


I fully agree with Mike, but I like to add another category; the no-fault
errors. The sensitivity of a diagnostic test is almost never 100%, e.g. a
chest X-ray has too little spatial resolution to detect small nodules and in
most patients missing them is an unavoidable misdiagnosis related to the
limitations of the test. But abandon chest X-ray and perform CT in every
patient is not the alternative.
(It is a different story when the selection of an imaging test is
inappropriate.)

So the message is that we should always be aware and prepared that we may be
wrong and be willing to reconsider a diagnosis.

This is not easy as excellently described by Kathryn Schultz in her book
³Being Wrong, adventures in the margin of error².  She explains why we are
so bad at imaging that we are mistaken.

Gerrit Jager

Op 07-02-19 15:59, Bruno, Michael <mbruno at PENNSTATEHEALTH.PSU.EDU> schreef:

> Thanks, Nelson,
>  
> Yes, I agree‹process changes, but also cognitive changes and an accommodation
> to our basic human biology.  I like to think of errors as falling into three
> categories: (1) those which are due to faults in our work processes, (2) t
> hose which are due to faults in our thinking, and (3) those which occur simply
> because of how we are made.  Each of these will be amenable to different
> solutions‹but only error detection after the fact addresses all three.
>  
> While there are a few diagnoses which, if missed, lead to immediate and
> irreparable harm, most do not.  If we learn to be inclined to expect, search
> for, and rapidly detect errors we will prevent harm MOST of the time.  In our
> experience in radiology, we do on regular occasion detect errors which have
> been present for several hours, such as when a finding is missed overnight but
> picked up on re-review in the morning.  In virtually all of these, patient
> harm was averted by correcting the diagnosis a few hours later.
>  
> All the best,
> 
> Mike
>  
>  
> 
> From: Nelson Toussaint [mailto:ntoussaint at tamarac.com]
> Sent: Thursday, February 07, 2019 8:36 AM
> To: 'Society to Improve Diagnosis in Medicine'; Bruno, Michael
> Subject: Kahneman interview - putting a premium on error detection
>  
>  
>  
> 
> February 7, 2019
> 8:16 AM 
> Michael
>  
> In Aerospace, it is anticipated that this behavior will occur.  Equipment will
> fail and people will make mistakes!  So, a concept of Accommodation is built
> into the process to counteract those faults that could lead to serious harm.
> In some cases you can detect the errors and in some the consequences are in
> play before you can confirm a detection.  So where real harm can appear, the
> Accommodation needs to be somewhat active before/as the fault occurs.
>  
> An example is the Ground Proximity Warning System, which estimates if the
> airplane may soon fly into terrain (navigation fault of the pilot or
> equipment).  This is only a warning and the pilot must take an action to
> change course.
>  
> Early detection of diagnostic error is good; but it still may not be in time
> to limit the potential harm.  A more robust process would include methods
> where the "conclusions" are reviewed before a diagnosis is complete.  One that
> comes to mind is what many of us use quite often - "what does this seem like
> to you"; a discussoin amongst involved parties such as the attending physician
> - radiologist/pathologist ­ patient.  This Accommodation can serve to cause
> the ³experts² to pause and reasses their findings.  It does not give a
> foolproof solution, but still allows the experts to continue to form the
> diagnosis.
>  
> This is just a thought, but it seems to me the process changes are the best
> way to attack this problem in order to get broad participation.  The trick
> will be how to modify the process without penalizing the many straight-forward
> cases.
>  
>   Nelson Toussaint
>  
> TAMARAC LLC
> 860-844-0199
> ntoussaint at tamarac.com <mailto:ntoussaint at tamarac.com>
>  
> 
> From: Bruno, Michael [mailto:mbruno at PENNSTATEHEALTH.PSU.EDU]
> Sent: Tuesday, February 05, 2019 12:41 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] Kahneman interview - putting a premium on error
> detection
>  
> Yes, thanks, Art!
>  
> It seems to me that while some errors are preventable, others may well be
> inevitable. The perceptual errors we were talking about at that session at DEM
> are probably biologically rooted (i.e., secondary to neurocognitive brain
> network functions) and are thus essentially outside of our conscious control.
> They are an example of an entire class of errors that flow from ³how we are
> made,² our biology and our evolution, and so they will not respond to the
> usual interventions, such as cognitive de-biasing, adult learning/CME, or even
> mindfulness. 
>  
> So it seems to me that, for these types of errors at least, there needs to be
> a premium placed on early error detection, so that errors can be more promptly
> detected and corrected before any patient harm is done.  That is the value of
> double-reading in radiology, and it may be an avenue where AI turns out to be
> particularly helpful in the years ahead.
>  
> All the best,
>  
> 
> Michael A. Bruno, M.D., M.S., F.A.C.R.
> Professor of Radiology & Medicine
> Vice Chair for Quality & Patient Safety
> Chief, Division of Emergency Radiology
> Penn State Milton S. Hershey Medical Center
> ( (717) 531-8703  |  6 (717) 531-5737
> * mbruno at pennstatehealth.psu.edu <mailto:mbruno at pennstatehealth.psu.edu>   |
> 
>  
> *****E-Mail Confidentiality Notice*****
> This message (including any attachments) contains information intended for a
> specific individual(s) and purpose that may be privileged, confidential or
> otherwise protected from disclosure pursuant to applicable law.  Any
> inappropriate use, distribution or copying of the message is strictly
> prohibited and may subject you to criminal or civil penalty.  If you have
> received this transmission in error, please reply to the sender indicating
> this error and delete the transmission from your system immediately.
>  
>  
> 
> From: Art Papier [mailto:apapier at VISUALDX.COM]
> Sent: Sunday, February 03, 2019 2:34 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] Kahneman interview
>  
> Thanks for sharing!   Great interview with many fascinating threads, and some
> new thoughts on the randomness of error, and how all error is not due to
> cognitive bias.  Towards the conclusion we hear that Dr. Kahneman in not a
> believer in cognitive debiasingŠ. saying essentially we are too busy making
> errors to recognize that we are making errors.  He asserts we should be
> thinking about how we recognize other peoples errors.  In made me think of the
> session at DEM on perceptual errors in diagnostic imaging and the very
> positive role of second reads in radiologyŠ.whether by humans or AI to
> recognize errors.  Perhaps either co-decision making, or AI ³second opinions²
> is an area we should all be further exploring.
> Best
> Art
>  
> Art Papier MD
> CEO VisualDx
> Associate Professor of Dermatology and Medical Informatics
> University of Rochester College of Medicine
>  
> 
> 
>  
> From: Xavier Prida <dr.xavier.prida at GMAIL.COM>
> Sent: Sunday, February 03, 2019 8:59 AM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: [IMPROVEDX] Kahneman interview
>  
> 
> On "thinking again"- not changing your mind, error, and bias - the latter two
> are not always linked.
> 
>  
> 
> https://onbeing.org/programs/daniel-kahneman-why-we-contradict-ourselves-and-c
> onfound-each-other-jan2019/
> <https://urldefense.proofpoint.com/v2/url?u=https-3A__onbeing.org_programs_dan
> iel-2Dkahneman-2Dwhy-2Dwe-2Dcontradict-2Dourselves-2Dand-2Dconfound-2Deach-2Do
> ther-2Djan2019_&d=DwMGaQ&c=_FmMnDvUH5queZcSmOuBzHZMbp7E7EwtGwv5cxxnTj0&r=XZJky
> 8Jx0OuETXcWpBMhx9j_wSYpSZPDVXdInJ5O9gQ&m=UrbAzwfML-iEIuCykgw2Fqn20pE6WrN96IDUM
> biOHMs&s=3X_IjCf1rsQokLp5q2wzaZqF1pXrJky5MKUV2tVppnQ&e=>
> 
>  
> 
> XEP
> 
>  
> 
>  praesent superare odio (rise above)
> 
>  
> 
> Xavier E. Prida MD FACC FSCAI
> 
> Assistant Professor of Medicine
> 
> Program Director Cardiology Fellowship Training
> 
> USF Morsani College of Medicine
> 
> Department of Cardiovascular Sciences
> 
> 2 Tampa General Circle
> 
> STC 5 th Floor 
> 
> Tampa, Fl 33606
> 
> 813 259 0992(O)
> 
>  
>  
> 
> 
> 
> 
> To unsubscribe from IMPROVEDX: click the following link:
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
> <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org
> _scripts_wa-2DIMPDIAG.exe-3FSUBED1-3DIMPROVEDX-26A-3D1&d=DwMGaQ&c=_FmMnDvUH5qu
> eZcSmOuBzHZMbp7E7EwtGwv5cxxnTj0&r=XZJky8Jx0OuETXcWpBMhx9j_wSYpSZPDVXdInJ5O9gQ&
> m=UrbAzwfML-iEIuCykgw2Fqn20pE6WrN96IDUMbiOHMs&s=PBCG5hjllVPSANZQoKcMqMD2ZiVXDp
> IMwesAc65piDE&e=>
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
> 
> <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org
> _scripts_wa-2DIMPDIAG.exe-3FINDEX&d=DwMGaQ&c=_FmMnDvUH5queZcSmOuBzHZMbp7E7EwtG
> wv5cxxnTj0&r=XZJky8Jx0OuETXcWpBMhx9j_wSYpSZPDVXdInJ5O9gQ&m=UrbAzwfML-iEIuCykgw
> 2Fqn20pE6WrN96IDUMbiOHMs&s=OeKMCzd2zeZiCtm1TGcYnGbJmDibC0OzIARvu7ewz1o&e=>
> 
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
> 
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
> <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.improvediagnosis.org_
> &d=DwMGaQ&c=_FmMnDvUH5queZcSmOuBzHZMbp7E7EwtGwv5cxxnTj0&r=XZJky8Jx0OuETXcWpBMh
> x9j_wSYpSZPDVXdInJ5O9gQ&m=UrbAzwfML-iEIuCykgw2Fqn20pE6WrN96IDUMbiOHMs&s=p9DtK4
> wdXsBYva9iE7z3eA3n1OqmC6On22QUAHNrHbo&e=>
>  
>  
> 
> 
> 
> 
> To unsubscribe from IMPROVEDX: click the following link:
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
> <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org
> _scripts_wa-2DIMPDIAG.exe-3FSUBED1-3DIMPROVEDX-26A-3D1&d=DwMFaQ&c=_FmMnDvUH5qu
> eZcSmOuBzHZMbp7E7EwtGwv5cxxnTj0&r=n5GC0R3w9jcHuCKxwuM7Hf8RiNko4O90e45rH34twIE&
> m=iRZnYLBXW_98lAxXmISASl94HhCeEaWW7QJXaxDu_tw&s=G_nkbwM3zjXrbSFsZspyy4Q7UwS14T
> MKbehSGipHfEE&e=>
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
> 
> <https://urldefense.proofpoint.com/v2/url?u=http-3A__list.improvediagnosis.org
> _scripts_wa-2DIMPDIAG.exe-3FINDEX&d=DwMFaQ&c=_FmMnDvUH5queZcSmOuBzHZMbp7E7EwtG
> wv5cxxnTj0&r=n5GC0R3w9jcHuCKxwuM7Hf8RiNko4O90e45rH34twIE&m=iRZnYLBXW_98lAxXmIS
> ASl94HhCeEaWW7QJXaxDu_tw&s=PTKjDDT0_CcAdZdHkueSf9c3hGE5bCtfYg0RsL5U-2A&e=>
> 
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
> 
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
> <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.improvediagnosis.org_
> &d=DwMFaQ&c=_FmMnDvUH5queZcSmOuBzHZMbp7E7EwtGwv5cxxnTj0&r=n5GC0R3w9jcHuCKxwuM7
> Hf8RiNko4O90e45rH34twIE&m=iRZnYLBXW_98lAxXmISASl94HhCeEaWW7QJXaxDu_tw&s=yA9UyS
> ZFBC0mFBmFXfuW14G9sh--1HsK31u2ZoL-EAw&e=>
> 
> 
> 
> 
> To unsubscribe from IMPROVEDX: click the following link:
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
>  or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
> 
> 
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
> 
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
> 







Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


HTML Version:
URL: <../attachments/20190209/c4417860/attachment.html> ATTACHMENT:
Name: image.png Type: image/png Size: 2281 bytes Desc: not available URL: <../attachments/20190209/c4417860/attachment.png> ATTACHMENT:
Name: image.png Type: image/png Size: 6043 bytes Desc: not available URL: <../attachments/20190209/c4417860/attachment-0001.png>


More information about the Test mailing list