Monday, August 6, 2018

99% of Doctors Need Diagnostic Help

Medical errors have become an accepted if unfortunate part of medical care, but physicians may greatly underestimate how much they contribute to the problem.

“The average clinician is making a lot of mistakes that they are unaware of,” says Dr. Art Papier, a dermatologist and medical informatics specialist. How many doctors fall into this category? All but the “master diagnosticians,” who represent less than 1% of practicing clinicians, he says. That would mean that 99% of doctors regularly make errors that they never realize they make.

Papier points to analyses of malpractice claims that show diagnostic errors are the largest cause of lawsuits, not bad outcomes of surgeries or baby deliveries as many people believe. And many of the missed diagnoses that lead to lawsuits are for common diseases such as cancer.
Fortunately, new decision support tools are available that can help streamline the diagnostic process and help clinicians more reliably get to the right answer. Some of these tools employ artificial intelligence (AI), which are techniques that enable computers to mimic human behavior, or they use machine learning, a subset of AI that uses statistical methods to enable machines to improve as they solve more problems.

The FDA has approved three AI-based tools this year for use in the clinic. The LVO Stroke Platform flags signs of stroke on computed tomography scans. The IDx-Dr device can be used by primary care clinicians to screen for diabetic retinopathy. The third device, OsteoDetect, is used to diagnose wrist fractures in adults.

Other tools are not regulated by the FDA, based on the level of decision-making still left to the clinician. Some are apps available for download to a smartphone. Papier is partial to an app produced by his company, VisualDx, which was highlighted by Apple CEO Tim Cook. It builds a database of clinical knowledge and images – including dermatologic images – that can be used at the point of care to help clinicians make accurate diagnoses. Although the app can be used for nondermatological diagnoses as well, skin presentations are a top need for primary care, emergency physicians and advanced practice providers, says Papier, CEO of VisualDx.

My Take:
There were several comments on this article by physicians, most of which focused on the need to take a good history and exam to make an accurate diagnosis. They complained about the lack of time allotted to properly do these procedures. They also stated that medical schools no longer provide enough education on these cornerstones of practice.

I agree with all those comments but would add that there is too much dependence on the diagnosis. In western medicine you have to reach a diagnosis to treat. Then you treat that label with little or no regard to the patient.

I prefer to develop a differential diagnosis that includes a few or even several possibilities. If, for example, a patient comes to my office with a diagnosis of RA (rheumatoid arthritis), my differential will include RA, but it will also include other possible conditions that may or may not be autoimmune in nature. My first goal is to reduce inflammation, regardless of cause. Whatever treatment is successful will narrow that differential diagnosis until we arrive at a more accurate diagnosis. You would be surprised how often that diagnosis of RA is wrong.

Bottom Line:
History and examination are, by far, the most important tools in any clinician’s repertoire. But labeling the patient with a definitive diagnosis does little to help you treat them effectively. Treating patients successfully is both a deductive and inductive process.

Source: July 26, 2018 National Institutes of Health

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