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Tuesday, January 15, 2019

The entire POINT of Health IT

Science-Based Medicine has a great new book review up.

"Cognitive Errors and Diagnostic Mistakes is a superb new guide to critical thinking in medicine written by Jonathan Howard. It explains how our psychological foibles regularly bias and betray us, leading to diagnostic mistakes. Learning critical thinking skills is essential but difficult. Every known cognitive error is illustrated with memorable patient stories..."
Stay tuned. I range far afield on this blog, episodically and recurrently addressing all manner of tangentially-related topics, but it always comes back to this: that which aids accurate dx reasoning is the entire point of "health information" and the technology that makes it available to clinicians. Anything that hampers that priority is to be identified and eliminated -- e.g., poor workflows (including those emanating from lousy HIT UX), useless administrative / compliance data burdens, myriad other distractions, etc.

But, tech is just a tool. Consistently scientific clinical reasoning is the goal. Again, SBM:
He includes a thorough discussion of the pros and cons of limiting doctors’ work hours, with factors most people have never considered, and a thorough discussion of financial motivations.

The book is profusely illustrated with pictures, diagrams, posters, and images from the Internet like “The Red Flags of Quackery” from Many famous quotations are presented with pictures of the person quoted, like Christopher Hitchens and his “What can be asserted without evidence can be dismissed without evidence”.

He never goes beyond the evidence. Rather than just giving study results, he tells the reader when other researchers have failed to replicate the findings.

We rely on scientific evidence, but researchers are not immune from bias. He describes the many ways research can go astray: 235 biases have been identified that can lead to erroneous results. As Ioannidis said, most published research findings are wrong. But all is not lost: people who understand statistics and the methodologies of science can usually distinguish a good study from a bad one…

1 Introduction 1
Summary 1
Errors in Medicine 2
Cognitive Biases 4
Cognitive Biases in Medicine 7
This Book 8
2 Ambiguity Effect 15
3 Bandwagon Effect and Authority Bias 21
Social Loafing and Diffusion of Responsibility 41
Reactance Bias 46
4 Confirmation Bias, Motivated Cognition, the Backfire Effect 57
Belief Bias 75
5 Curse of Knowledge 89
6 Decision Fatigue 93
7 Feedback Sanction 103
8 Financial Bias 109
Mere Exposure Effect and Norm of Reciprocity 122
9 Forer Effect 139
10 Framing Effect and Loss Aversion 145
Sunk Costs, Endowment Effect, Choice-Supportive Bias 150
Anchoring Effect 155
Contrast Effect 163
11 Affective Error 169
Attribution Biases:​ The Fundamental Attribution Error and Self-Serving Bias 183
12 Gambler’s Fallacy and Hot Hand Fallacy 203
13 Hasty Generalization, Survival Bias, Special Pleading, and Burden of Proof 211
Survival Bias, Special Pleading, and Burden of Proof 225
14 Hindsight Bias and Outcome Bias 247
False Memories 254
15 Illusionary Correlation, False Causation, and Clustering Illusion 265
16 In-Group Favoritism 285
17 Information Bias 303
18 Nosology Trap 307
19 Omission Bias 321
Commission Bias 327
20 Overchoice and Decision Avoidance 345
21 Overconfidence Bias 351
22 Patient Satisfaction Error 369
23 Premature Closure:​ Anchoring Bias, Occam’s Error, Availability Bias, Search Satisficing, Yin-Yang Error, Diagnosis Momentum, Triage Cueing, and Unpacking Failure 379
Introduction 379
Anchoring Bias 379
Occam’s Error 386
Availability Heuristic 389
Search Satisficing 396
Yin-Yang Error 404
Diagnosis Momentum 406
Triage Cueing 408
Unpacking Failure 414
Failure-To-Close Error 417
24 Representativene​ss Bias 425
Base Rate Neglect 429
Zebra Retreat 438
25 Screening Errors 445
26 Selection Bias and Endowment Effect 457
Introduction 457
Application Steps 457
27 Semmelweis Reflex 467
 Galileo Fallacy 473
28 Systems Errors 501
Alarm Fatigue 501
Defensive Medicine 506
Graded Clinician Error 511
The Electronic Medical Record Error 514
29 Blind Spot Bias 525
30 Research Errors 537
Introduction 537
Expectation Bias 538
P-Hacking and HARKing 541
File Drawer Effect/​Publication Bias 546
Poor Surrogate Outcomes 547
Non-Representative Study Populations:​ 548
Citation Plagiarism 549
Lack of Replication 549
Predatory Publishers 551
Conflicts of Interest 553
Legal Threats 554
Ghostwriting 555
Fraud 556
Solutions 559
Conclusion 565
Index 577

BTW: A cautionary prior post of mine: "Treat the numbers instead of the patient?"

See also my prior post "Clinical cognition in the digital age."

Having had the great fortune to teach "critical thinking" at the university level for a number of years, this stuff goes to my wheelhouse and prime interests.

BTW, highly recommend this SBM book as well.


From THCB, the "aSOAP note?" Comment by Leo Holm, MD
The patient chart has needed revolution for a long time now. Too many obstructionists like the AMA, CMS, MGMA and other groups who think a complete review of systems means anything other than trolling the patient. I guess they need a legacy bridge to guard to keep themselves relevant. We need a patient centered form of documentation with the concision that will serve doctors and patients alike. Unfortunately, there do not seem to be any “disruptive innovators” in this realm. This has been exacerbated by the data mongers who want every morsel of information as structured data…even though they don’t have the slightest idea of what to do with it that would be meaningful for patients. The obfuscation and disorganization of critical patient data is dangerous, and the ones who are causing it need to be held accountable. That was a good first shot for putting together a far more meaningful note.
Interesting. See my prior post "EBM and the SOAP process."
" mongers who want every morsel of information as structured data… even though they don’t have the slightest idea of what to do with it that would be meaningful for patients."
Hmmm... See "Are structured data the enemy of health care quality?"

"SOAP?" "SOAPe?" "aSOAP?" "POMR?"

Let's recap, shall we?
"That which aids accurate dx reasoning is the entire point of "health information" and the technology that makes it available to clinicians. Anything that hampers that priority is to be identified and eliminated."
Back to where we began. It's worth mentioning that that extends beyond tech to clinical pedagogy. "How doctors (are trained to) think."

Beyond those categories of concerns, how about our hardy little enervating perennial, the problematic "productivity treadmill?"

UPDATE: "Everything you believe is WRONG"



Intriguing crew

…While burnout has long been a worry in the profession, the report reflects a newer phenomenon — the draining documentation and data entry now required of doctors. Today’s electronic record systems are so complex that a simple task, such as ordering a prescription, can take many clicks.

Doctors typically spend two hours on computer work for every hour they spend with patients, the report said. Much of this happens after they leave the office; they call it “pajama time.”

Medicine has become more regulated and complex over the past several years, generating what doctors often consider to be meaningless busywork detached from direct patient care. That’s when they start to feel disheartened, authors of the report said.

“A lot of physicians feel they are on a treadmill, on a conveyor belt,” said Dr. Alain A. Chaoui, president of the Massachusetts Medical Society and a family doctor in Peabody…
Not exactly "news." I've listened to these gripes going all the way back to the DOQ-IT era more than a decade ago.


Experts Declare Physician Burnout ‘a Public Health Crisis’ – and Health IT a Significant Pathogen
Posted on January 24, 2019 by Yves Smith

Yves here. Replying on the work of the health care and IT experts writing at Health Care Renewal, we have been writing about how electronic health care records are a danger to sound medical practice. Among other things, they are designed for billing, not diagnosis or treatment, force doctors to waste time dealing with pages of mechanical drop-downs, and distract them from paying attention to patients…
Interesting post. What bothers me is that in some quarters you're only an "expert" if you're a health IT critic.

More to come...

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