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Thursday Complexity Post
February 5, 2015

Collaboration May Improve Medical Diagnoses 


Doctors working in teams may make more accurate diagnoses than doctors working alone, a recent study suggests.


German researchers recruited 88 fourth year medical student volunteers and showed them videos of simulated patient cases. They then asked the volunteers to select one of 20 possible diagnoses, and order from a menu of 30 possible tests. Twenty eight of the students worked individually and the remaining 60 worked in pairs. Those working in pairs were 18 percent more accurate in their diagnoses. The study also found that pairs were more likely to differ in confidence about the diagnosis when the diagnosis was incorrect.   


The researchers said superior accuracy of the pairs could not be explained by differences in knowledge or relevant information. "Collaboration may have helped correct errors, fill knowledge gaps and counteract reasoning flaws," researcher Dr. Wolf E. Hautz and colleagues said. The findings appeared in a research letter in the Journal of the American Medical Association.


A story by Sabriya Rice in reports that as many as one out of 20 adults in the U.S. may be misdiagnosed in outpatient visits, and about half of those errors could be harmful.


While hospitals have developed systems for monitoring healthcare acquired infections and surgical errors and other patient safety issues, experts say systems for tracking diagnostic mistakes barely exist and causes of diagnostic error have not been thoroughly researched. The 1999 Institute of Medicine Report "To Err is Human" brought medical error into public consciousness but did not focus on diagnostic error. The IOM report due this fall is expected to probe diagnostic error. Complicating the issue, Rice writes, is that there is no universally accepted definition of a diagnostic error.   


According to a 2014 study by CRICO Strategies, a Cambridge, Mass.-based risk-management group, about 20 percent of 23,527 medical malpractice cases filed between 2008 and 2012 were related to diagnostic concerns, she reports, and about 73 percent of the 4,705 diagnostic claims alleged lapses in clinical judgment, such as failure to order diagnostic tests, establish a differential diagnoses or give a referral.


Some surveys and research indicate time and scheduling pressures contribute to the potential for error.


Maine Medical Center, a part of MaineHealth in Portland, began an innovative initiative to get clinicians thinking about diagnoses. The hospital's patient-safety officer and clinical educator started a pilot project that ran from January to July 2011 where doctors voluntarily discussed examples of diagnostic mistakes. During the trial period, doctors found 36 instances where diseases such as cancer, stroke and pneumonia were missed, misdiagnosed or not identified in a timely fashion. "Just about every time you talk to clinicians involved in diagnostic errors, it seems like time and volume is an issue," said Dr. Robert Trowbridge, an internal medicine physician who teaches clinical reasoning at Maine Medical Center.


Dr. Gordon Schiff, a diagnostic error researcher at Brigham and Women's Hospital in Boston, told that diagnosis is really a team effort. He said the idea that diagnosis is "this heroic, lone ranger thing" that doctors do behind closed doors is romantic and outdated.


Share your thoughts on the Complexity Matters blog.  



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Liberating Structures, Complexity, and Relational Coordination
Guests: Jeff Cohn, Keith McCandless, Tony Suchman, and Jody Hoffer Gittell                     


Conventional wisdom suggests that incremental change and transformational change are opposites. Small relational changes generate marginal results and big formal changes are needed to transform an organization. Makes perfect sense. Too perfect.


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By liberating many small adaptive and relational changes, is it possible to achieve critical mass? By doing so are we shifting attractor patterns? Are we changing the microdynamics and habits that underpin culture? Do we have theories that explain the surprising or better-than-expected results often generated through the practice of Liberating Structures, Relational Coordination, and Adaptive Positive Deviance? Do these theories explain how small changes generate big results and big efforts can change nothing?


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