Medicine and art have been "intertwined" since antiquity, but as the cultures of art, technology, and science became distinct and discordant in recent time, much of the connection has been lost.
ImproveDx Blog
The Centers for Disease Control and Prevention (CDC) is engaged in many efforts with the laboratory community and other partners to reduce diagnostic errors, both domestically and internationally. CDC's Division of Laboratory Systems (DLS) works to strengthen the nation's clinical and public health laboratory system by continually improving quality and safety, informatics and data science, and workforce competency.
As human enterprise—business, government, academia, law, healthcare—grows more complex, so do the teams that do the work. Teams that tackle "wicked" problems and complicated initiatives often include diverse membership representing specialized, disparate skills and knowledge. These cross-industry and multidisciplinary teams, including those that work on diagnosis, offer advantages but also challenges that must be addressed if the team is to be successful.
In the latest issue of Diagnosis, Annemarie Jutel examines how physicians have reacted to patients who consult sources of information on their own to learn about their diseases and conditions. Patient access to information is currently a hot topic, but Jutel traces the debate back through more than 100 years. Often, the patients who are seen to be disruptive are attempting to self-diagnose prior to consulting a physician.
Robert "Bob" L. Wears, MD, MS, PhD, distinguished professor of emergency medicine at the University of Florida College of Medicine–Jacksonville, died peacefully on July 16, 2017, with his family at his side.
As we mourn the passing of Lawrence Weed, the father of the problem-oriented medical record (POMR), the SOAP note format, and problem-knowledge couplers, we also celebrate his life and ideas. Weed is known best for those contributions and for his travels across the country in the 1970s, during which he advocated standardizing the medical record as an aide to guide thinking.
Not all errors are created equal, especially in medical imaging. Some are familiar and common in medicine; others, such as perceptual errors, are specific to radiology and difficult to correct.
In Improving Diagnosis in Healthcare, the Institute of Medicine (IOM; now the National Academy of Medicine) reported the frequent occurrence of misdiagnosis and patient harm, which escalated calls to improve clinical reasoning in practice. A key recommendation from the book is to improve diagnosis during healthcare professional training. Preliminary evidence suggests that physicians tend to practice in a style similar to how they were trained. Regardless of the content of their formal education, they pick up the culture of the institution.
Clinical reasoning has been called "the clinician's quintessential competency," one that is foundational for successful diagnosis. Current discussions about how best to teach and assess clinical reasoning include debate about what it is and how it relates to diagnostic reasoning. Among those discussing how to assess clinical reasoning, organizations that certify physicians have already been working to ensure that their testing methods help physicians maintain and advance this competency.
As a frequent subject of malpractice suits,1 diagnostic error can hardly be called an emerging risk. But many providers and other healthcare professionals, including risk managers, are just beginning to understand and address it. As a member of the Steering Committee for the Coalition to Improve Diagnosis, the American Society for Healthcare Risk Management (ASHRM) was one of the organizations that took an early lead in raising awareness of diagnostic error.
Opioid overdose deaths surged after 1999 and sharply since 2012, reaching 33,091 deaths in 2015—63.1% of all overdose deaths, and more than car accidents that year. Despite the opioid crisis being recognized as a public health emergency, IHI found 33 uncoordinated intervention programs with little success. Diagnosis itself hasn't been examined as a contributing factor—a lens that may offer new understanding and solutions.
For years, members of the the Society to Improve Diagnosis in Medicine have been debating the proper relationship between articifial intelligence and the diagnostic reasoning of physicians. In The New Yorker, Siddhartha Mukherjee considers that question and goes beyond to learn how computers learn.
Intelligence and intellectual curiosity are necessary for success in medical school but not sufficient for effective clinical practice. In the past, medical students focused exclusively on science and technical medical skills. But with growing awareness that patient safety and quality improvement should be part of medical education, training in other aspects of practice has gained acceptance. Human factors engineering, communication, and teamwork are among those additional competencies. Physicians should learn how, as well as what, to practice.
A 13-year-old's sudden death triggered a misdiagnosis cascade: without post-mortem genetic testing, his brother's long QT syndrome diagnosis was assumed to explain the death, leading over 24 relatives to be diagnosed with it too. A Mayo Clinic second opinion found no genetic evidence of long QT syndrome — the boy's death was actually a different, non-familial heart condition. Mayo physicians said a molecular autopsy would likely have prevented the cascade, and that clinicians had over-relied on the testing company's interpretation over phenotyping.
Measurement is central to improving the safety, quality, and value of healthcare services. There is debate, however, about what and how to measure and the potential for measurement to result in unintended consequences. Does desire for data focus our attention only on things that are easy to count, concealing problems that don't lend themselves to measurement? Do documentation requirements drain physicians' time and attention, to the detriment of patient care? Do patients find the information provided by quality measures helpful? Do they trust it?
In a large national study in England and Wales, researchers found higher rates of mortality among patients with acute myocardial infarction (AMI) who initially had received a different diagnosis. In earlier work, the researchers found an association between a lack of evidence-based care for AMI prior to a hospital visit and increased mortality. They believe this is the first attempt to quantify the effect on clinical outcomes of missing an initial diagnosis of AMI.
Although empathy and compassion are central to topics of current interest, including burnout, patient satisfaction, and medical and nursing education, the terms are often loosely defined, and research about their role in medicine has been scarce.1 That is beginning to change.
Unlike other sectors, healthcare has been slow to adopt digital tools, with clinicians often distrusting imperfect systems and chaotic social media even as consumers easily track and research health online. Still, the internet offers real opportunities for diagnostic safety work—breaking down silos and hierarchies by widening access to evidence, building larger networks, and enabling real-time feedback beyond mere marketing.
Clinical reasoning combines fast, intuitive pattern recognition (System 1) and slower analytical thinking (System 2), both improvable through decision support—colleagues, literature, or computerized systems—each with tradeoffs. Time pressure, under-resourced practices, and stigma around asking for help often discourage physicians from seeking it. Still, technological and generational shifts are improving decision support's use, and the Institute of Medicine's Improving Diagnosis in Health Care calls for more research into health IT's potential to aid diagnosis.
During a strategic planning retreat in the spring of 2013, leaders of the Society to Improve Diagnosis in Medicine (SIDM) asked themselves, "What can we do that would have the most impact on improving diagnosis?" (ML Graber, email communication, November 2015). To Err Is Human,1 the Institute of Medicine (IOM) report about medical error, attracted national attention when it was released in 19992 and spawned the current patient safety movement.