{"id":2540,"date":"2022-01-31T10:19:03","date_gmt":"2022-01-31T18:19:03","guid":{"rendered":"https:\/\/phcprimarycare.org\/?p=2540"},"modified":"2022-01-31T10:19:03","modified_gmt":"2022-01-31T18:19:03","slug":"diagnostic-accuracy-part-i-in-a-series","status":"publish","type":"post","link":"https:\/\/phcprimarycare.org\/?p=2540","title":{"rendered":"Diagnostic Accuracy (Part I in a series)"},"content":{"rendered":"<p><strong>By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer<\/strong><\/p>\n<p>In 2001, the Institute of Medicine (IOM) published <em>Crossing the Quality Chasm<\/em>, which defined 6 realms of quality:<\/p>\n<ul>\n<li>Safe<\/li>\n<li>Effective<\/li>\n<li>Patient Centered<\/li>\n<li>Timely<\/li>\n<li>Efficient<\/li>\n<li>Equitable<\/li>\n<\/ul>\n<p>Most quality improvement and quality assurance activities related to health care address one or more of these realms.\u00a0 However there is one critical area that is missing from both the IOM realms and most QI plans.\u00a0 This missing realm is at the heart of what it means to be a clinician, is infrequently measured and is uncomfortable to verbalize.<\/p>\n<p>This realm is <strong>Accuracy<\/strong>, in particular the diagnostic accuracy of clinicians.<\/p>\n<p><u>Diagnostic Inaccuracy<\/u>:\u00a0 Studies show that between 5 and 50% of diagnoses are erroneous, depending on the type of patient\/problem.\u00a0 The low range applies to a population of patients where most are normal; the high range applies to a population where all patients have complex abnormalities.\u00a0 Autopsy studies and studies with \u201csecret shopper\u201d patients show rates of inaccuracy of between 10 to 20%.\u00a0 (Mark Graber:\u00a0 \u201cThe Incidence of Diagnostic Error in Medicine\u201d, BMJ October 2013)<\/p>\n<p>What is the source of this diagnostic inaccuracy?<\/p>\n<p>At the core is an insufficient appreciation of uncertainty.\u00a0 Put another way, clinicians and scientists are often overconfident in the accuracy of their decisions.\u00a0 This psychological trait develops when we are trainees, as it makes us appear confident in the eyes of our patients, and helps prevent us from being paralyzed by indecision.\u00a0 Fortunately, many medical conditions in primary care resolve on their own, so neither the clinician nor the patient ever become aware of the inaccuracy.<\/p>\n<p>We can reduce diagnostic inaccuracy by changing the <em>way<\/em> that we think.<\/p>\n<p>Daniel Kahneman (winner of the 2002 Nobel Prize in Economics) describes two ways of thinking:<\/p>\n<ol>\n<li>Fast thinking (also known as intuitive thinking or system I thinking)<\/li>\n<li>Slow thinking (also known as rational thinking or system II thinking)<\/li>\n<\/ol>\n<p><u>Fast, intuitive thinking<\/u> tends to be automatic, with input from emotions.\u00a0 In his book, <em>Thinking Fast and Slow<\/em>, Dr. Kahneman notes 12 different classes of bias and 5 heuristics which can lead to irrational decisions, when we think intuitively.<\/p>\n<p><u>Slow, rational thinking<\/u> is more deliberative, systematic, and logical, with an evaluation of consequences of a decision.<\/p>\n<p>As we go through our everyday lives and routine practice of medicine, we use fast thinking for most decisions, so we can get through our days without being paralyzed by indecision over minor decisions.\u00a0 When the stakes are high, or when we notice a diagnostic pattern that doesn\u2019t quite fit, we need to transition to slow, rational thinking.\u00a0 For a clinician to be efficient <em>and<\/em> accurate, we need to know when to toggle back and forth between slow and fast thinking.<\/p>\n<p>When slow thinking is associated with a retrospective analysis of a serious diagnostic error, as happens in morbidity and mortality rounds, or when a clinician becomes aware of a diagnostic error that occurred, it is good to explicitly think about which biases or heuristics contributed to the error, to help prompt us to move to slow thinking when needed.<\/p>\n<p>This process is sometimes called \u201ccognitive debiasing,\u201d which is a fancy way of saying \u201clearning from our mistakes\u201d.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer In 2001, the Institute of Medicine (IOM) published Crossing the Quality Chasm, which defined 6 realms of quality: Safe Effective Patient Centered Timely Efficient Equitable Most quality improvement and quality &hellip; <a href=\"https:\/\/phcprimarycare.org\/?p=2540\">Continue reading <span class=\"meta-nav\">&rarr;<\/span><\/a><\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"jetpack_post_was_ever_published":false,"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[1],"tags":[30],"class_list":["post-2540","post","type-post","status-publish","format-standard","hentry","category-uncategorized","tag-diagnostic-accuracy"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v26.2 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Diagnostic Accuracy (Part I in a series) - PHC Primary Care Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/phcprimarycare.org\/?p=2540\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Diagnostic Accuracy (Part I in a series) - PHC Primary Care Blog\" \/>\n<meta property=\"og:description\" content=\"By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer In 2001, the Institute of Medicine (IOM) published Crossing the Quality Chasm, which defined 6 realms of quality: Safe Effective Patient Centered Timely Efficient Equitable Most quality improvement and quality &hellip; Continue reading &rarr;\" \/>\n<meta property=\"og:url\" content=\"https:\/\/phcprimarycare.org\/?p=2540\" \/>\n<meta property=\"og:site_name\" content=\"PHC Primary Care Blog\" \/>\n<meta property=\"article:published_time\" content=\"2022-01-31T18:19:03+00:00\" \/>\n<meta name=\"author\" content=\"RMoore\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"RMoore\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"3 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/phcprimarycare.org\/?p=2540\",\"url\":\"https:\/\/phcprimarycare.org\/?p=2540\",\"name\":\"Diagnostic Accuracy (Part I in a series) - PHC Primary Care Blog\",\"isPartOf\":{\"@id\":\"https:\/\/phcprimarycare.org\/#website\"},\"datePublished\":\"2022-01-31T18:19:03+00:00\",\"author\":{\"@id\":\"https:\/\/phcprimarycare.org\/#\/schema\/person\/e2261897cb15c2610b283200b210f79c\"},\"breadcrumb\":{\"@id\":\"https:\/\/phcprimarycare.org\/?p=2540#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\/\/phcprimarycare.org\/?p=2540\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\/\/phcprimarycare.org\/?p=2540#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\/\/phcprimarycare.org\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Diagnostic Accuracy (Part I in a series)\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\/\/phcprimarycare.org\/#website\",\"url\":\"https:\/\/phcprimarycare.org\/\",\"name\":\"PHC Primary Care Blog\",\"description\":\"Partnership HealthPlan of California\",\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\/\/phcprimarycare.org\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"en-US\"},{\"@type\":\"Person\",\"@id\":\"https:\/\/phcprimarycare.org\/#\/schema\/person\/e2261897cb15c2610b283200b210f79c\",\"name\":\"RMoore\",\"image\":{\"@type\":\"ImageObject\",\"inLanguage\":\"en-US\",\"@id\":\"https:\/\/phcprimarycare.org\/#\/schema\/person\/image\/\",\"url\":\"https:\/\/secure.gravatar.com\/avatar\/f0ba7e9946a1ad594a0070ed009f75ea00cb69b3f7271511fd722377966e54bd?s=96&d=mm&r=g\",\"contentUrl\":\"https:\/\/secure.gravatar.com\/avatar\/f0ba7e9946a1ad594a0070ed009f75ea00cb69b3f7271511fd722377966e54bd?s=96&d=mm&r=g\",\"caption\":\"RMoore\"},\"url\":\"https:\/\/phcprimarycare.org\/?author=2\"}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"Diagnostic Accuracy (Part I in a series) - PHC Primary Care Blog","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/phcprimarycare.org\/?p=2540","og_locale":"en_US","og_type":"article","og_title":"Diagnostic Accuracy (Part I in a series) - PHC Primary Care Blog","og_description":"By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer In 2001, the Institute of Medicine (IOM) published Crossing the Quality Chasm, which defined 6 realms of quality: Safe Effective Patient Centered Timely Efficient Equitable Most quality improvement and quality &hellip; Continue reading &rarr;","og_url":"https:\/\/phcprimarycare.org\/?p=2540","og_site_name":"PHC Primary Care Blog","article_published_time":"2022-01-31T18:19:03+00:00","author":"RMoore","twitter_misc":{"Written by":"RMoore","Est. reading time":"3 minutes"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"WebPage","@id":"https:\/\/phcprimarycare.org\/?p=2540","url":"https:\/\/phcprimarycare.org\/?p=2540","name":"Diagnostic Accuracy (Part I in a series) - PHC Primary Care Blog","isPartOf":{"@id":"https:\/\/phcprimarycare.org\/#website"},"datePublished":"2022-01-31T18:19:03+00:00","author":{"@id":"https:\/\/phcprimarycare.org\/#\/schema\/person\/e2261897cb15c2610b283200b210f79c"},"breadcrumb":{"@id":"https:\/\/phcprimarycare.org\/?p=2540#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/phcprimarycare.org\/?p=2540"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/phcprimarycare.org\/?p=2540#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/phcprimarycare.org\/"},{"@type":"ListItem","position":2,"name":"Diagnostic Accuracy (Part I in a series)"}]},{"@type":"WebSite","@id":"https:\/\/phcprimarycare.org\/#website","url":"https:\/\/phcprimarycare.org\/","name":"PHC Primary Care Blog","description":"Partnership HealthPlan of California","potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/phcprimarycare.org\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"en-US"},{"@type":"Person","@id":"https:\/\/phcprimarycare.org\/#\/schema\/person\/e2261897cb15c2610b283200b210f79c","name":"RMoore","image":{"@type":"ImageObject","inLanguage":"en-US","@id":"https:\/\/phcprimarycare.org\/#\/schema\/person\/image\/","url":"https:\/\/secure.gravatar.com\/avatar\/f0ba7e9946a1ad594a0070ed009f75ea00cb69b3f7271511fd722377966e54bd?s=96&d=mm&r=g","contentUrl":"https:\/\/secure.gravatar.com\/avatar\/f0ba7e9946a1ad594a0070ed009f75ea00cb69b3f7271511fd722377966e54bd?s=96&d=mm&r=g","caption":"RMoore"},"url":"https:\/\/phcprimarycare.org\/?author=2"}]}},"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/p293xY-EY","_links":{"self":[{"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=\/wp\/v2\/posts\/2540","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=2540"}],"version-history":[{"count":1,"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=\/wp\/v2\/posts\/2540\/revisions"}],"predecessor-version":[{"id":2541,"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=\/wp\/v2\/posts\/2540\/revisions\/2541"}],"wp:attachment":[{"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2540"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=2540"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/phcprimarycare.org\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=2540"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}