Wait, What’s This? by Stephen Vaughn MD, PhD

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The Institute of Medicine has released a new study, entitled Improving Diagnosis in Health Care. ISBN 978-0-309-37769-0 That’s a fascinating topic, so I dug into the report. Ominously, it was published by the COMMITTEE ON DIAGNOSTIC ERROR IN HEALTH CARE.

This thing will change medicine, or accelerate the change – and not in a good way.

Evidently, the Committee is concerned about the poor quality of diagnosis in the United States – it is so bad, we scarcely even understand it:

“First, Improving Diagnosis in Health Care exposes a critical type of error in health care—diagnostic error—that has received relatively little attention since the release of To Err Is Human. There are several reasons why diagnostic error has been underappreciated, even though the correct diagnosis is a critical aspect of health care. The data on diagnostic error are sparse, few reliable measures exist, and often the error is identified only in retrospect. Yet the best estimates indicate that all of us will likely experience a meaningful diagnostic error in our lifetime.”

The report, all 473 pages of it, will join the IOM’s series on the revolution in modern American medicine.

A scant fifty pages or so are used to explore the diagnostic process itself.

“Diagnosis” is now a team activity – “Diagnostic team members include patients and their families and all health care professionals involved in their care.”

The committee, with its expertise on diagnosis, describes how we humans actually think. The current understanding of clinical reasoning is based on the dual process theory, a widely accepted paradigm of decision making. The dual process theory integrates analytical and non-analytical models of decision making (see Box 2-4). Analytical models (slow system 2) involve a conscious, deliberate process guided by critical thinking (Kahneman, 2011). Nonanalytical models (fast system 1) involve unconscious, intuitive, and automatic pattern recognition (Kahneman, 2011).

This model, unfortunately, describes how INDIVIDUALS think – not how diagnostic team member collaborate in diagnosis. Surprisingly, the new model lumps therapy into diagnosis:

“Diagnostic Error: Error or delay in diagnosis; failure to employ indicated tests; use of outmoded tests or therapy; failure to act on results of monitoring or testing.”

Similarly, a diagnosis cannot be said to be complete until the patient is informed, as he/she is a member of the diagnostic team:

“The committee’s patient-centered definition of diagnostic error is: the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient….The definition frames a diagnostic error from the patient’s perspective, in recognition that a patient bears the ultimate risk of harm from a diagnostic error. The committee’s definition is two-pronged; if there is a failure in either part of the definition, a diagnostic error results.”

”Overdiagnosis” is described as a process that nears but does not satisfy the definition of diagnostic error. Over-diagnosis is the detection of a disease process in the patient which will not result in morbidity or mortality. It needs to be rooted out, just like diagnostic error.

There is growing recognition that overdiagnosis is a serious problem in health care today, contributing to increased health care costs, overtreatment, and the associated risks and harms from this treatment (Welch, 2015; Welch and Black, 2010).

The pathway to correct thinking is set out in stone, and diagnosis, like treatment, is established within set parameters of thinking. You are responsible for diagnosing diseases that are not yet understood, and for which there are no thinking guidelines – that is being strictly patient-centered.:

“There could be situations in which clinicians and health care organizations, practicing conscientiously (e.g., following clinical practice guidelines or established standards of care), may be unable to establish a definitive diagnosis. For example, individuals may have signs and symptoms that have not been recognized universally by the medical community as a specific disease. From the patient’s perspective, this could be a diagnostic error, but medicine is not an exact science, and documenting and examining such instances could provide an opportunity to advance medical knowledge and ultimately improve the diagnostic process.”

The leading paragraph of Chapter 3 repeats the word “committee” so frequently as to be noteworthy.

“This chapter explains the committee’s definition of diagnostic error, describes the committee’s approach to measurement, and reviews the available information about the epidemiology of diagnostic error. The committee proposes five purposes for measurement: to establish the incidence and nature of the problem of diagnostic error; to determine the causes and risks of diagnostic error; to evaluate interventions; for education and training purposes; and for accountability purposes. Because diagnostic errors have been a very challenging area for measurement, the current focus of measurement efforts has been on understanding the incidence and nature of diagnostic error and determining the causes and risks of diagnostic error. The committee highlighted the way in which various measurement approaches could be applied to develop a more robust understanding of the epidemiology of diagnostic error and the reasons that these errors occur.”

Curiously, however, when it comes to liability, risk and responsibility, the ball’s still in the PHYSICIAN’S lap for diagnostic error. You will be required to report your mistakes, and you will be help accountable for them.

Recommendation 4a: Accreditation organizations and the Medicare conditions of participation should require that health care organizations have programs in place to monitor the diagnostic process and identify, learn from, and reduce diagnostic errors and near misses in a timely fashion. Proven approaches should be incorporated into updates of these requirements.

Recommendation 4b: Health care organizations should:
• Monitor the diagnostic process and identify, learn from, and reduce diagnostic errors and near misses as a component of their research, quality improvement, and patient safety programs.
• Implement procedures and practices to provide systematic feedback on diagnostic performance to individual health care professionals, care teams, and clinical and organizational leaders.

Recommendation 4c: The Department of Health and Human Services should provide funding for a designated subset of health care systems to conduct routine postmortem examinations on a representative sample of patient deaths.

That’s about as much as I picked up while at lunch today at Il Vicino. The document reads as though written as a passionate exegesis of history according to some cultlike ‘ism – Marxism, Communism, Trotskyism, Maoism, Freudianism. Words are taken out and given their Newspeak meanings – guideline, diagnosis, diagnostic error, overdiagnosis. They have jargonized Newspeak meanings.

The IOM has asserted, or created from whole cloth, the supposition that diagnostic error is one of the new counterrevolutionary forces impeding progress. It will need to be defined, diagnosed and punished, largely by people who couldn’t diagnose a head cold. Diagnosis is to spring from The People’s Conscience – that is, the team consensus held by the least-experienced member.

Interestingly, it is available in paperback for $69.95 (15% discount if you sign up with NAP); alternatively, the e-book can be licitly downloaded for free, here. At $69.95 it is overpriced – free, it is just depressing.
Don’t say I didn’t give ya something this Holiday Season!

PS: A little further on, I discover (p219)

El-Kareh et al. (2013, p. ii40) asserted that “[u]naided clinicians often make diagnostic errors” because they are “[v]ulnerable to fallible human memory, variable disease presentation, clinical disease processes plagued by communication lapses, and a series of well-documented ‘heuristics,’ biases and disease-specific pitfalls.” It is widely recognized that health IT has the potential to help health care professionals address or mitigate these human limitations.”

The triumph of silicon over carbon, perhaps.

“For instance, algorithms can be developed that periodically scan EHRs for diagnostic errors or clinical scenarios that suggest a diagnostic error has occurred. An example of the former would be cases of patients with newly diagnosed pulmonary embolism who were seen in the 2 weeks preceding diagnosis by an outpatient or emergency department clinician with symptoms that may have indicated pulmonary embolism (e.g., cough, shortness of breath, chest pain).”
When we see a patient with a cough, and miss a pulmonary embolus, what makes it now classified as a “diagnostic error?”

In the traditional tort structure of common law, it is when there is tangible evidence which would lead a reasonably competent colleague to diagnose the condition. Now, the ER doctor(s) who have seen the patient and not diagnosed a PE, have made a medical error. Whether or not the patient wishes to litigate against you, and any others who have not diagnosed a PE, is up to the patient, and her/his attorney. Sounds uncomfortable?

“because of the richness of the data source (of malpractice litigation,) this method could also be helpful in identifying the reasons why diagnostic errors occur. However, there are limitations with malpractice claims data because these claims may not be representative; few people who experience adverse events file claims, and the ones who do are more likely to have experienced serious harm.”

Remember, this is not being written by a malpractice lawyers’ organization, but the prestigious Institute of Medicine. Harm, in the legal sense, is the objective demonstration of damage that is a consequence of malpractice.

Taken in summary – get rid of doctors, you get rid of doctors’ errors.

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  3 comments for “Wait, What’s This? by Stephen Vaughn MD, PhD

  1. Seneca
    January 3, 2016 at 10:39 am

    Reality is more bizarre than fiction. Looks like the ‘bots will soon rule, at least for the proletarians. The “dear leaders” among us will likely still be able to choose a carbon based doctor.

    I’m nearly 58 and looking for the (professional) exit. Never would have thought this at the beginning of my career; in fact, I anticipated working at some level well into my ’70’s.

    • Steve Vaughn MD
      January 3, 2016 at 12:38 pm

      We’re ’bout the same age, Seneca. The ‘logic’ of the decision-making today is vacuous. You know, the “yay for bots” movement has been going on since Charlie Chaplin’s days – and so has the attempt to force automation into medicine.

      It’s not failed because people didn’t try hard enough. It’s failed because it sucks and doesn’t work. Nevertheless, every couple of generations, people try the “Tower-of-Babel” approach to human intelligence – “Okay, now we’re so fricking smart, we can DO it this time!” Another try, another Titanic.

      The Twilight Zone Marathon just on this week was chock full of short scenarios demonstrating the problems with ‘bots. The conflicts are no different now then they were then.

      No idea is ever so bad that it will disappear on its own.

    • Perry
      January 3, 2016 at 4:51 pm

      Time to look at alternative employment.

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