In which a neurologist writes a bad study claiming we are all idiots

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@johnny_bananas, what do you mean? an African or European swallow?
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That line was asked to a specific character in the movie. That shall be your quest, then you will know.
 
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Janders said:
Vascular events
Infection
Cancer.

Very finite small buckets with easy directed solutions.
Click to expand...
We've finally figured out the cause of all preventable death!

Problem is, it's life.
 
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In all seriousness, I do think it's worth looking at the finding that "15 clinical conditions accounted for 68% of diagnostic errors associated with high-severity harms".

I suspect we'll find that some aren't worth intervening upon (I don't intend to cure old age) while others are.
 
Janders said:
Vascular events
Infection
Cancer.

Very finite small buckets with easy directed solutions.
Click to expand...

Now I see why my "insights" weren't published.

100% of deaths in my study were attributable to just 4 conditions:

-Asystole
-PEA
-VF
-VT

If we could fix just 4 conditions, we'd be immortal!

But 4 is more than 3. Scooped yet again.
 
I’m not seeing the outrage. The diagnostic error rate from these data sets is what it is; it may be close to accurate, it may be off by several orders of magnitude. Who cares? What makes me think that it may be closer to reality is that fact that EM’s performance is right on par with other out-patient specialities - despite all of the challenges inherent to working in the ED. So, to the extent that a diagnostic accuracy problem exists, it would be a health system issue, not an EM specialty problem.

The other aspect of the study that seems to comport with prior experience and data is that a small proportion of illnesses are responsible for a disproportionate number of missed diagnoses and harm. They are the common offenders - missed stroke, MI, vascular and cord catastrophes, etc. They are the classic atypical presentations of lethal diseases or lethal diseases masquerading as common ailments that are the bane of our existence. The paper even notes the problem with testing inaccuracies when dealing with these drivers of bad outcomes. Again, this would suggest that EPs are lacking the hardware (tests) rather than the software (expertise) to make the diagnosis.

No, I don’t think that this paper should have been blasted out to the lay media in the manner that it was. We can thank the mentality that drives us to Tweet every finding as soon as it passes peer review for that. On the other hand, we need to think long and hard about how much treasure we want to spend to try and improve this “problem” because it’s going to take an expensive system overhaul to meaningfully improve it.

Oh, and then there is the issue of doctors calling doctors idiots behind the anonymity of the internet. Yeah, this is why we lose.
 
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ShockIndex said:
I’m not seeing the outrage. The diagnostic error rate from these data sets is what it is; it may be close to accurate, it may be off by several orders of magnitude. Who cares? What makes me think that it may be closer to reality is that fact that EM’s performance is right on par with other out-patient specialities - despite all of the challenges inherent to working in the ED. So, to the extent that a diagnostic accuracy problem exists, it would be a health system issue, not an EM specialty problem.

The other aspect of the study that seems to comport with prior experience and data is that a small proportion of illnesses are responsible for a disproportionate number of missed diagnoses and harm. They are the common offenders - missed stroke, MI, vascular and cord catastrophes, etc. They are the classic atypical presentations of lethal diseases or lethal diseases masquerading as common ailments that are the bane of our existence. The paper even notes the problem with testing inaccuracies when dealing with these drivers of bad outcomes. Again, this would suggest that EPs are lacking the hardware (tests) rather than the software (expertise) to make the diagnosis.

No, I don’t think that this paper should have been blasted out to the lay media in the manner that it was. We can thank the mentality that drives us to Tweet every finding as soon as it passes peer review for that. On the other hand, we need to think long and hard about how much treasure we want to spend to try and improve this “problem” because it’s going to take an expensive system overhaul to meaningfully improve it.

Oh, and then there is the issue of doctors calling doctors idiots behind the anonymity of the internet. Yeah, this is why we lose.
Click to expand...
We lose because we're in an end-stage capitalism hellscape within a society that has aggressively discourages feelings of connection. Docs calling other docs idiots is a time honored tradition (I'm remembering surgery M&Ms in the late 90s) that has possibly improved with time.

In response to the "small number of diseases account for majority of misses" argument, I think that's subtly wrong. What the paper is really saying is that a small number of diseases account for the majority of plaintiffs' claims. That's going to favor diseases that have a clear and catastrophic outcome attributable to a single (or closely grouped together series of) healthcare encounters. It's going to miss diseases where blame is difficult to parse out, diseases that affect populations that have unequal access to legal representation, and diseases that are occurring in patients with expected poor outcomes. Reviewing cases across multiple groups has shown that we miss ,for example, delirium far more commonly than MI/stroke/acutely ischemic limb/sepsis.

I will spot that "Hard to diagnosis diseases account for the majority of missed diagnoses" is not a sexy statement.
 
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As a Neurologist/Neurointensivist I sincerely apologize for this Monday-morning-quarterback of a study conducted by a "Vestibular Neurologist" that has likely not stepped foot in the Hopkins ED in 10 years to emergently address a patient with acute onset vertigo. Last I checked, EM doctors are doing the same HINTS exam with expedited MRI Brain as Neurologists do. Acute onset vertigo is difficult, even for the seasoned Neurologist. One of the best Stroke Neurologists I've ever worked with saw a 70ish YO M in the ED with a normal HINTS exam, no signs at all of central etiology of vertigo, and a normal NCHCT/CTA 4 hours after hyperacute vertigo onset. The patient was admitted for "vestibular rehab for peripheral vestibulopathy" to Medicine (not Neuro admitting service) and had to go to the OR 2 days later with malignant posterior fossa edema requiring a suboccipital crani for large cerebellar stroke. People in glass houses should not throw stones.

It is cute for a Neurologist that literally specializes in one disease family (vertigo) to criticize EM doctors for mistakes in a syndrome that is notoriously difficult to diagnose accurately, all while that same EM physician is also tasked with not missing a single MI, handling high risk pregnant women, acute traumas, pediatrics in many cases, septic shock . . . everything.

The most shameful thing is that this Neurologist at Hopkins has created a whole research career of "missed diagnosis" and has other doctors following him in the pipeline.
 
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BoardingDoc said:
Ahh, and I was mistaken. That is in fact the bridge troll who Arthur asks that to, not to Tim who led them to the murderous rabbit and the ultimate use of the holy hand grenade. I clearly need to watch it again. It's probably been a decade. Mea culpa.
Click to expand...

There are some who call me..................Tim?
 
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RustedFox said:
I thought it was the two castle guards in the early scenes of the film. But then remembered the bridge of death.
Click to expand...
The castle guards are the ones who imbue Arthur with that knowledge.

G: Are you suggesting coconuts migrate?

A: Not at all! It could be carried.

G: What, by a swallow?

A: It could grip it by the husk!

G: It's not a question of where it grips it. It's a simple matter of weight ratios. A 5 oz bird cannot carry a 1 pound coconut!

A: Look, if you would just tell your master....

G: An African swallow, maybe, though african swallows are non-migratory

Apologies for errors, again, it's been a decade. I've added a re-watch to my calendar for tomorrow night..
 
I wrote a thing:
www.acepnow.com

An Incorrect Report on Emergency Department Diagnostic Errors - ACEP Now

ACEP Now offers real-time clinical news, news from the American College of Emergency Physicians, and news on practice trends and health care reform for the emergency medicine physician. ACEP Now is an official publication of the American College of Emergency Physicians.
www.acepnow.com www.acepnow.com
 
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xaelia said:
I wrote a thing:
www.acepnow.com

An Incorrect Report on Emergency Department Diagnostic Errors - ACEP Now

ACEP Now offers real-time clinical news, news from the American College of Emergency Physicians, and news on practice trends and health care reform for the emergency medicine physician. ACEP Now is an official publication of the American College of Emergency Physicians.
www.acepnow.com www.acepnow.com
Click to expand...
Excellent breakdown of the terrible methods of this "meta-analysis". The authors spent years on a fishing expedition, only caught a muddy shoe, and are trying to tell us that muddy shoe is a 20 pound fish.
 
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ProReduction said:
Excellent breakdown of the terrible methods of this "meta-analysis". The authors spent years on a fishing expedition, only caught a muddy shoe, and are trying to tell us that muddy shoe is a 20 pound fish.
Click to expand...
Well, unfortunately it seems that the media and public are more than happy to eat that shoe and tell each other it's bluefin.

Dude, @xaelia --Thank you and Bravo! That's the best piece I've read months, if not years.
 
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