D&$%@& if you do D&$%@& if you don’t.
By David L Meyers, MD, FACEP
I recently attended two international meetings focusing on diagnostic errors. In early September, the first international conference on “Preventing Overdiagnosis” took place in Hanover, NH, sponsored by the Dartmouth Institute for Health Policy & Clinical Practice in conjunction with Consumer Reports, The British Medical Journal and Bond University (Queensland, Australia). The subtitle of the conference, “winding back the harms of too much medicine”, succinctly sums up the theme explored in detail throughout the three days of presentations, by speakers from all over the world, some of whom are household names.
To me, the participation of Consumer Reports was especially interesting. As readers of that publication know, they have been focusing on health and medical care issues for some time, devoting editorial content to costs and appropriateness of care, antibiotic overuse, unnecessary testing and other related matters. The Chairman of Consumers Union, Jim Guest, was one of the keynote speakers. As an early promoter of the ABIM Foundation’s Choosing Wisely campaign, he made an impassioned plea for more attention to that program, seen as a serious effort to counter the massive health care spending for tests and procedures of doubtful effectiveness and value and poising potential harm.
Many of the other speakers recounted the harm and cost related to too much testing and treatment. Big Pharma was especially criticized for creating demand when there was little or no clinical evidence for it - think ads for “Low T” and a host of other medicines advertised directly to consumers. The issues surrounding screening for breast cancer (mammography), prostate cancer (PSA testing) and lung cancer among many other diseases were also discussed. Our own Jay Schuur, MD, FACEP led an interesting break-out session on the ED diagnosis of pulmonary embolism. For those who wish to delve further into conference topics, hundreds (literally) of abstracts are on-line via the Preventing Overdiagnosis web site and many of the presentations are available on Youtube.
Less than 2 weeks later, the Society to Improve Diagnosis in Medicine (SIDM) held their 6th annual conference, “Diagnostic Errors in Medicine (DEM): Define, Measure, Improve”, at the Feinberg School of Medicine at Northwestern University in Chicago. The focus of this group, which also counts among its attendees and members very prominent opinion leaders and researchers in the field, including a large contingent of emergency physician thought leaders, has historically been on under- and misdiagnosis.
This year’s keynote speakers were Christine K. Cassel, MD, a prominent physician leader at Mt. Sinai School of Medicine and now with the National Quality Forum, Brent C. James, MD, MStat, a widely renowned quality and measurement guru from Intermountain Health Care, and Bob Wachter, MD, one of the founders of hospitalist medicine and a prominent medical thinker at the University of California-San Francisco Medical Center. Drs. Cassel and Wachter were also Board Chair and President respectively of the American Board of Internal Medicine.
A series of sessions devoted to a research summit and educator’s workshop and courses in the basic concepts of diagnostic errors and cognitive psychology surrounding human decision-making and biases preceded the formal DEM conference. Emergency Physician Karen Cosby, MD participated as faculty in the “Intro to Diagnostic Error” session.
The conference opened with Dr. Cassell’s presentation on increasing the focus on diagnostic errors, which the Harvard Malpractice study notwithstanding, have had much less attention than other causes of patient harm in the nearly 15 years since the Institute of Medicine published “To Err Is Human” in 1999. The next 2 ½ days were filled with presentations across many medical specialties and disciplines addressing their respective diagnostic error problems and possible approaches. As at previous DEM conferences, significant discussions addressed the roles of System 1 and System 2 thinking, a model proposed by Kahnemann and Twersky in their seminal paper which led to Kahnemann’s Nobel award in Economics. Ideas about how to deal with our innate biases led to lively discussions about “de-biasing,” sensitizing to awareness of biases and other ways to make our diagnostic decision-making more robust and less error prone. The slide presentations from this conference are posted on www.improvediagnosis.org.
I made note that at these two meetings very little was presented to help negotiate the minefields we in the ED and virtually every other diagnostic practitioner face every day between overtesting/overdiagnosis and undertesting/missed and mis-diagnosis. I and several others raised questions related to this problem in the large sessions, but they got no real traction. We tried to raise the possibility of these two groups combining efforts and looking more broadly at these areas, but there was little interest. One of these days, that will have to happen.
I am on the planning committee for the DEM conference next year which will be held at Emory University in Atlanta, September 14-17, 2014. I am happy to talk to anyone about my experiences and invite you to suggest ideas for topics and speakers of interest. I guarantee an interesting and lively learning experience next year and I urge all of our QIPS Section members to consider attending a future conference on these topics.
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