Diagnostic time out

What is a diagnostic time out? Succinctly defined, it’s a deliberate exercise in differential diagnosis and systematic clinical reasoning in the care of an individual patient. But wait, I hear someone say… isn’t that what we do already? Well, no. We’re all familiar with the traditional model for clinical reasoning that we’re taught in medical school but those of us in the real world of practice nowadays, if we’re honest, realize that it seldom happens. There’s just not enough time when you’re forced to see too many patients each day. And hospitalist incentives, with their emphasis on speed and quick adoption of specific diagnostic labels, run in opposition. What do we as hospitalists do instead? Well, aside from all the care pathways and metric incentives that tell us what to do, we rely on clinical instincts and rules of thumb. Because they bypass formal analysis, they save time. They serve as cognitive shortcuts. We call these heuristics. This method of thinking (fast, instinctive, intuitive) is sometimes known as system 1 thinking. It has the advantages of being efficient and fast and sometimes, in critical situations, life saving. But it comes at the cost of a certain error rate. In order to better understand the process of system 1 thinking we have given the various heuristics names and categories. I recently listed some of those in this post. 

If system 1 is our usual measure of processing to get around time constraints the alternative is system 2: formal clinical reasoning .  System 2 thinking was the topic of a recent paper in CriticalCare Clinics. Although based on a survey of people working in a NICU the article has general applicability. The authors contrast system 1 and system 2 thinking in this manner:

Dual process theory holds that individuals engaging in medical decision-making use one of 2 distinct cognitive processes: a system 1 process based on heuristics – the use of rapid pattern recognition and rules of thumb – or a system 2 process, based on deliberate analytical modeling and hypothesis generation. While invoking system one processes individuals can think fast and reflexively and can even operate at a subconscious level, using pattern recognition to sort vast amounts of clinical information quickly before an illness script that allows for the rapid elaboration of a differential diagnosis. In contrast system 2 processes require focused attention and are purposefully analytical, relying on deliberate counter-factual reasoning to generate hypotheses regarding the pathophysiologic mechanisms by which a patient’s symptoms are produced.

The authors introduced the concept of the diagnostic time out to describe this shift of thinking because it requires deliberate effort. It’s not going to arise spontaneously in the natural course of the ward routine. (The authors were not the first ones to use this term). The diagnostic time out can be considered the cognitive equivalent of the better known procedural time out.

Why is a diagnostic time out needed? Research on diagnostic error has indicated that while some instances are due to system problems (such as failure to communicate test results) most are cognitive errors. These can be linked to the heuristics of system 1 thinking. The diagnostic time out, or the deliberate exercise of system 2 thinking, is a way to complement these cognitive shortcuts with a more analytical process.

Some opinion leaders in the field of diagnostic error have suggested universal adoption of system 2 thinking. This is problematic due to time constraints. Besides, there are some essential benefits of system 1 thinking, particularly in acute life-threatening situations. The real trick is how best to selectively employ system 2 thinking. In other words what are the situations in which system 2 thinking should be used? The authors suggest handoff situations in complex patients including ER to hospitalist, off service/on service and ICU to ward transfers.

How does it work? The authors propose a template but it’s really just the traditional clinical reasoning process. One of their points really got my attention: during the time out diagnostic labels should be removed and replaced by signs, symptoms, manifestations and clinical concerns. This of course is the opposite of what your coders and hospitalist leaders want you to do.

What are some of the barriers to implementation? In addition to time constraints, fear of ambiguity is an important factor. We are afraid to admit what we don’t know. One thing you will never hear a hospitalist say out loud is “I’ll have to think about that.”

Who are the most influential ER docs on Twitter?

Find out here.

We must be careful. Social media, where power and influence often surpass truth, may be contributing to the post-modernization of medicine.

The principal barrier to implementation of palliative care: misunderstanding of what it is

That point was brought out again in this study, which focused on heart failure patients:

We interviewed 18 physician, nurse practitioner, and physician assistant providers from 3 specialties: cardiology, primary care, and palliative care. Providers had limited knowledge regarding what palliative care is, and how it can complement traditional HF therapy to decrease HF‐related suffering. Interviews identified several potential barriers: the unpredictable course of HF; lack of clear referral triggers across the HF trajectory; and ambiguity regarding what differentiates standard HF therapy from palliative care...

Conclusions Palliative care referral for HF patients may be suboptimal due to limited provider knowledge and misperceptions of palliative care as a service reserved for those near death.

Why is there such widespread misperception? Because no one has done an adequate job of defining what palliative care really is. A while back I went on a search for clarity on this subject. After identifying what I thought was the best article available on the topic I realized that even it failed. In a post in which I linked to that article I pondered why no one has defined palliative care and concluded, shockingly, that the true definition of the role of palliative care is an embarrassment to our profession. That's right. As I said in the post (emphasis added):

So lots of helpful information there. But the authors fail in one aspect. They fail to define palliative care. They talk around it but don't define it. As I've become comfortable with the idea of palliative care in recent years I've come to know what it is. Despite that, no one has precisely articulated a definition that I know of.

If palliative care is a specialty as the authors claim, what are the distinctives? Again, we need a definition. A definition has two steps. First it places the thing under discussion in a general category. Then it lists attributes that distinguish that particular thing from other members of the same category. For example, step 1: Palliative care is a medical discipline.. Step 2: characterized by ?????. There's the hard part. What are the distinguishing characteristics of palliative care? The authors list quite a few characteristics. The problem is those characteristics don't distinguish palliative care from other disciplines of medicine: Palliative care focuses on severe illness in patients with multiple and complex problems. It applies expertise to the management of a variety of symptoms. It educates patients and their families on diagnosis, prognosis and the goals of treatment. It coordinates complex care across multiple disciplines and settings.

Do you begin to see the problem here? Palliative care is nothing more than good primary care. Or what an excellent internist or hospitalist should be doing. So yes, there is a definition for palliative care but it goes unspoken because the profession is, or should be, embarrassed by the fact that we need a “specialty” whose focus is to offload the rest of us from doing all those things that make for excellence in comprehensive care because we don't have the time.

There's an emerging data set which informs us that palliative care is very high value care because it saves money while increasing quality of life and maybe even survival. But that's nothing more than saying that time spent with patients, excellence in care and coordination across transitions improves lives and saves money. Palliative care can rightly claim “We specialize in excellence.” What that, the fact that we need a special “service” to deliver excellence, says about the rest of us who are increasingly pushed toward mediocrity by performance metrics and time pressures, goes largely unspoken.

Metrics, medical collectivism and the disenfranchisement of physicians

Recent changes in the culture of health care are undermining clinical excellence. Watch this grand rounds presentation from the University of Arizona!

Fake doctor notes in Wisconsin: civil disobedience or something else?

The other day physician and journalist Ford Vox wrote a piece on the ethics and consequences of the fake medical excuses written by doctors in the Department of Family Medicine at the University of Wisconsin. In saying that the docs failed to understand the impact of their action on public perception of the profession, he was right. In crediting them with an act of civil disobedience he missed the boat:

Members of the University of Wisconsin's Department of Family Medicine, including both residents and attendings, felt compassion for the educators' cause, and wanted to participate in the display, but rather than symbolically protest in the streets alongside the teachers, they decided to perform an act of civil disobedience: The doctors wrote out fake sick notes for the teachers, many of whom were falsely using illness as an excuse to attend the protests..

Wrong. Civil disobedience is open. Say you wanted to protest U.S. military spending. An act of civil disobedience might be to openly refuse to pay income tax. It would not be an act of civil disobedience to cheat on your income tax even if you rationalized that the morality of your use of the money would exceed that of Uncle Sam. If that's too rude an analogy it illustrates the point. The doctors in Wisconsin may have thought they were demonstrating for social change but they were being, to use not so rude a term, disingenuous.


Also consider that those who commit true civil disobedience are open in facing the consequences of their actions. The Wisconsin doctors were not. When approached by reporters and videographers the docs offered lame (and unintentionally hilarious) defenses or told the reporters to get lost. One wonders if any of them, especially the residents involved, counted the cost in advance.


This little stunt may have been the use of the profession as a vehicle for social change but it wasn't true civil disobedience.

Fake notes by real docs in Wisconsin---anything new?

It's been over six months since faculty members of the University of Wisconsin department of Family Medicine made a stir when they decided social activism should trump evidence based medicine in the treatment of individual patients, and made a public display of it. Things have been quiet in the blogs after an initial splash, so I decided to search for updates and found a couple of recent news items.


The status of things, it would appear, is up in the air as investigations are ongoing at two levels---the state medical board and the University. Details will eventually be made public.

Theocracy hysteria

This post is worth the read if only for the concluding sentence:

Theocracy is forever descending on the United States, but somehow it always lands in the Middle East.

Tattoos---are they safe?

You’d think so now that the procedure is more refined and mainstream. Well---

Is the culture of medicine headed in the right direction?

The external environment is driving it the other way according to Beth Haynes, MD. Go read the article and note the choice Berwick quote. HT to the Black Ribbon Project.

Detroit's implosion

Non-medical but interesting.


Detroit is about the only city left that St. Louis can make fun of. And that's pretty bad.

Fake-notes-real-docs update

Via Unlikely Hospitalist.

The Cooley and DeBakey feud

Here's a history of the feud between the two men, and it's final resolution, from Dr. Cooley's perspective.

Idolizing the democratization of knowledge

---leads to more and more tabloid medicine, and we're not necessarily better off for it.

Stan the Man receives the Medal of Freedom

From the St. Louis Post Dispatch:

WASHINGTON - Stan Musial joined leading politicians, cultural heroes and human rights leaders today in receiving the Presidential Medal of Freedom, the nation's highest civilian honor.

I grew up watching Stan the Man. I started going to Cardinal games at the age of eight. My father was acquainted with Leo Ward, traveling secretary for the Cards, and we had the opportunity to watch some games from his box seats on the first base line at Busch Stadium I, AKA Sportsman's Park, where we saw Stan “up close and personal” when he played first base.

Stan was loyal to the St. Louis fans and never wanted to play for any other team. He once offered to take a cut in pay during a slump. One time my dad was dining at Stan's restaurant. There was Stan sweeping the floor.

It's great to see him honored in this way. He's been one of the game's under rated players.

National Anthem flub

I try to ignore the Super Bowl, so I missed this.



It seems at major sporting events some singer always tries to outdo the performance of the year before. The theatrics applied to the National Anthem are getting ridiculous. As Gateway Pundit suggested, why not tone it down and concentrate on the words?

JAMA commentary proposes adding emotion and passion to scientific articles

Some medical journals such as JAMA and the Annals of Internal Medicine occasionally publish emotional articles that convey the human side of medicine. Many journals, NEJM notable among them, also weigh in on political issues. Appropriately, the emotional and political content is clearly compartmentalized from the scientific content. A commentary writer in the December 8 issue of JAMA seems to think that may not be a good thing:

What if science were presented in the same passionate, emotional style as in those accounts of personal experiences that moved the physician who wrote them? Instead of requiring a science article to have the standard introductory, methods, results, and discussion sections with a certain number of words and a certain number of tables, science articles should perhaps include cartoons, pictures, or emotional images that contain meaning and require the use of both the right and left brain. Perhaps permitting the personal would not degrade the scientific process but rather increase the likelihood that the information contained in the journals would actually be read, absorbed, and used.

Apparently the author, Robert H. Brook, MD, of the Rand Corporation, thinks the dispassionate language of scientific papers is too dry to be useful. Earlier in the paper he wrote:

...scientific articles are written in a manner that, in many instances, adopts a bland, somnolent tone. The language has no passion, conveys no emotion. The words stimulate no visual image. Physicians have been taught to present their science in what is called a “flat manner”: let the facts speak for themselves.

That's what Dr. Brook thinks is wrong with scientific articles. What nonsense. Steve Milloy, in his book Junk Science Judo, wrote, on page 46:

...keep the slow, steady ho-hum scientific method in mind. Boring? Sure. Tedious? You betcha. Slow and deliberative? Be grateful.

Dr. Brook seems to start with a faulty premise: that the purpose of a research article is to persuade. Wrong. Persuasion is an art which almost by definition introduces fallacies. That's what Aristotle laid out in his textbook on Rhetoric. He described the three elements of persuasion: ethos, pathos and logos. Scientific papers confine themselves to logos. Bring in the other two elements and you introduce all sorts of emotionally driven fallacies such as appeals to fear, passion and belief. More than that, allowing an author's emotions and passions in a scientific paper would deliberately permit and even introduce bias.


It's true that doctors need to be persuaded to incorporate the best evidence into practice. But please, not in original scientific papers. There are other appropriate places and methods to accomplish that. Imagine if clinical investigators passionately spun the results right in their own research articles! It would make a joke of scientific journals.


As an aside I note this little gem of an observation Brook makes midway through the paper:

However, the world of communication has changed. Today, the Internet, Facebook, LinkedIn, and all sorts of connected devices allow humans to immediately share photographs, emotions, thoughts, and passions. It is difficult to imagine a young physician growing up in this communication environment, trying to focus his or her brain on science studies that seem to be written in a language as foreign as medieval English would be to modern inhabitants of the British Isles.

Here Brook comes dangerously close to saying that social media has dumbed down science education for a whole generation of students! Could it be? I'm not sayin'. U r free 2 read n 2 that what u want 2 LOL.

“The core of her appeal is her deep love for freedom”

Anne C. Heller on Ayn Rand.



Via Instapundit.

The male ogling reflex bypasses the neocortex

“It's a reflex that's built into the brain circuits,” she said in an interview. “At its core biological basis, it's unfair to criticize men for that initial unconscious circuitry.”

In light of this, male ogling must henceforth be considered genetic destiny rather than anti-social creepiness.

I guess it's how you process it in your neocortex afterwards that counts.

Via Instapundit.

Hedonism your thing?

There's an app for that.

Chilling.

What not to give

---on Father's Day.

From Huffington Post via Orac.