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When You Hear Hoofbeats Think of Zebras, too?

  • 1.  When You Hear Hoofbeats Think of Zebras, too?

    Posted 22 days ago
    Interesting article: When the Hoofbeats Are Zebras



    David

    David L Meyers, MD, MBE, FACEP
    Mobile: 410-952-8782



  • 2.  RE: When You Hear Hoofbeats Think of Zebras, too?

    Posted 21 days ago
    Thanks, David!  Cool paper!!

    There was a nice article in the WSJ a few years ago, featuring our own Dr. Hardeep Singh, which discussed cognitive biases in the diagnostic process.  One of them was called "Zebra Retreat," in which doctors were overly reluctant to make a diagnosis of a disease they thought was rare, i.e., a zebra.

    If anyone has that article, it would be nice to share it with the group.  It was published at least 5-6 years ago, maybe more.

    Mike





  • 3.  RE: When You Hear Hoofbeats Think of Zebras, too?

    Posted 21 days ago
    Michael: I don't recall seeing the WSJ paper. We originally described the Zebra Retreat and its multiple features in a paper in Academic Emergency Medicine (attached).
    A chapter in our recent book 'The Cognitive Autopsy' describes the bias in a clinical context (pdf attached)- Case 13 - The Postpartum Puzzler, See Box 13.1 for an expansion of its characteristics.
    Pat






  • 4.  RE: When You Hear Hoofbeats Think of Zebras, too?

    Posted 21 days ago

    Here is the Wall Street Journal article that you mentioned.  It is behind a paywall so only the first few paragraphs appear here:

    The Biggest Mistake Doctors Make

    Misdiagnoses are harmful and costly. But they're often preventable.





    SF










  • 5.  RE: When You Hear Hoofbeats Think of Zebras, too?

    Posted 20 days ago
      |   view attached

    Thanks Sherrill;  I couldn't find the attachment, so here it is again....   Lauro Landro has featured stories on dx errors for many years now.

     

    Mark Graber

     




    Attachment(s)



  • 6.  RE: When You Hear Hoofbeats Think of Zebras, too?

    Posted 19 days ago
    Thanks, Mark!  Thanks Sherill!!

    Mike





  • 7.  RE: When You Hear Hoofbeats Think of Zebras, too?

    Posted 20 days ago
    Here are some of my thoughts about this interesting discussion of cognitive issues and diagnostic errors.
    1. The overall diagnostic accuracy rate in practice has been reported to be 85 to 90 percent, which means that close to 9 out of 10 patients are diagnosed accurately in practice.
    2. If all human beings, including physicians have cognitive heuristics and biases and if these are a major cause of diagnostic errors, we should not be seeing this very high diagnostic accuracy rate in practice.
    3. My own view is that diagnosis is essentially a scientific process characterized by hypothesis generation and hypothesis testing.
    4. Diagnostic errors occur primarily due to failure to suspect a disease from a presentation and formulate it as a hypothesis and to a lesser extent by failure to test a hypothesis properly.
    5. A disease is not usually suspected if its presentation is highly atypical or if it is rare (a zebra).
    6. It is of intertest that the currently prescribed Bayesian method encourages failure to suspect a zebra as the very low prior probability of this disease is interpreted as very strong prior degree of belief against it in this method.
    Bimal
    Bimal Jain MD
    Salem Hospital/Mass General Brigham
    Salem MA 01970

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  • 8.  RE: When You Hear Hoofbeats Think of Zebras, too?

    Posted 19 days ago
    Thanks, Pat!   I assume Laura Landro & the WSJ were referencing your paper when they mentioned "Zebra Retreat."

    Mike





  • 9.  RE: When You Hear Hoofbeats Think of Zebras, too?

    Posted 19 days ago
    I hope the annual SIDM meeting continues to have sessions on cognitive biases; how to recognize them, analyze them and prevent them

    I have found the last few SIDM meetings to be moving away from that critically important discussion and to be focusing on EMR methodologies and "tricks" that focus on improving communication between clinicians (which is relevant obviously but doesnt address the primary driver of dx error in my opinion....)

    Thank you for your consideration

    Thomas Westover MD






  • 10.  RE: When You Hear Hoofbeats Think of Zebras, too?

    Posted 19 days ago
    Thomas: of course, I and a growing number of others will agree with you.
    If the upcoming AHRQ report maintains its conclusion that cognition is our biggest problem, as it should, then we should all be aware of the various ways in which cognition fails us.
    The social sciences, independently, have confirmed that human cognition is a flawed business.
    There is an ethical imperative before us to hold these in mind as we continue to work on the diagnostic process.
    Pat Croskerry MD, PhD





  • 11.  RE: When You Hear Hoofbeats Think of Zebras, too?

    Posted 18 days ago
    Every story of medical error I have told in Medical Malpractice Insights - Learning from Lawsuits has been the result of errors due to one or more of the 3 C-s: "Cognition," "Communication" and/or "Conception (Pre-), aka "bias." I agree that DEM's biggest opportunities lie in getting us all to "think better."

    ------------------------------
    Charles Pilcher MD FACEP
    Editor, Medical Malpractice Insights - Learning from Lawsuits
    https://madmimi.com/p/5f4487
    ------------------------------



  • 12.  RE: When You Hear Hoofbeats Think of Zebras, too?

    Posted 18 days ago





  • 13.  RE: When You Hear Hoofbeats Think of Zebras, too?

    Posted 18 days ago
    Thanks for this link. It was a very useful session.

    Sent from my iPhone

    David
    David L Meyers, MD  MBE FACEP
    410-952-8782





  • 14.  RE: When You Hear Hoofbeats Think of Zebras, too?

    Posted 17 days ago
    With all due respect to those who put so much stock in cognition as the critical piece of diagnosis that needs to be improved, I still maintain that cognition (thinking) does not happen in a pure state, like a brain in a bell jar surrounded by nourishing fluid! Or like Charles van Doren in the isolation booth of Twenty One (the 1950s quiz show where even he had to cheat to get all the right answers). Cognition happens in the messy world of production pressures, explicit and implicit biases, distractions, inadequate information, misaligned incentives, forgetfulness, emotions, faulty application of Bayesian reasoning, etc, etc, etc.  

    Not to digress, but who would think that surgery performed on a surgeon's birthday is more likely to lead to patient mortality than surgery s/he performs on other days - attributed by the study's authors to "life-event distractions." (BMJ 2020 doi: https://doi.org/10.1136/bmj.m4381)

    The recommendations in the IOM/NAM report Improving Diagnosis in Health Care forces us to rethink the diagnostic process beyond a conceptualization of it "as a solitary activity, taking place exclusively within an individual physician's mind." Specifically, the report recommended the following:

    Goal 1: Facilitate more effective teamwork in the diagnostic process among health care professionals, patients, and their families.

    Goal 2: Enhance health care professional education and training in the diagnostic process.

    Goal 3: Ensure that health information technologies support patients and health care professionals in the diagnostic process.

    Goal 4: Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice.

    Goal 5: Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance.

    Goal 6: Develop a reporting environment and medical liability system that facilitates improved diagnosis by learning from diagnostic errors and near misses.

    Goal 7: Design a payment and care delivery environment that supports the diagnostic process.

    Goal 8: Provide dedicated funding for research on the diagnostic process and diagnostic errors.

    I see no specific mention of cognition in the above, and, in fact, "cognition" is not even defined in any of the IOM/NAM reports in the Quality Chasm series which addresseas errors and harm in health care.

    PS, I don't think news reports of huge malpractice awards have much impact beyond the clinicians who are the subjects of the claims.

    Just sayin'.

    DLM








  • 15.  RE: When You Hear Hoofbeats Think of Zebras, too?

    Posted 16 days ago
    I agree with David, especially on Goal 6:
    Goal 6: Develop a reporting environment and medical liability system that facilitates improved diagnosis by learning from diagnostic errors and near misses.
    Why? Because we're still living in a "Blame and Shame" environment where we do everything possible to bury the outcomes of our most egregious errors: the ones become med mal lawsuits settled pre-trial with confidentiality clauses. We learn nothing and the same mistakes are repeated. Med Mal Insights anonymizes such stories into 3-4 minute reads and keeps the learnings simple. Seems to resonate with the 4200+ readers.
    Sorry if my contributions to this discussion are on a less academic level than most. As an ER doc in a community hospital, "Sick" or "Not Sick" is about as academic as I get. Then I call one of you. David knows the drill, but at on a much higher plain.

    ------------------------------
    Charles Pilcher MD FACEP
    Editor, Medical Malpractice Insights - Learning from Lawsuits
    https://madmimi.com/p/5f4487
    ------------------------------



  • 16.  RE: When You Hear Hoofbeats Think of Zebras, too?

    Posted 16 days ago
    I agree with both David and Charles.
    One observation that has emerged over recent years is that the diagnostic process itself appears far more complex than originally thought. As mentioned earlier,in one paper over 50 independent variables were identified, all with possible non-linear effects as well as second and higher order interactions. I have to say that surgeon's birthday was not one of them.
    And, of course, cognition is everywhere, in all the things we do. Other than spinal reflexes, all our behaviors are preceded by some sort of cognitive process, even if it is subconscious and autonomous (as many biases are).
    Medicine does not have a long history of being interested in cognitive processes, but at the end of the day it might be (something similar to) the Holy Grail for those interested in clinical decision making.
    Pat Croskerry MD, PhD