Editors’ Note: This letter is in response to a comment on Terry Graedon’s recent editorial, “Is Larry Weed Right?”
Abstract
Keywords: Misdiagnosis, diagnostic error, information overload, diagnostic software, evidence-based medicine, participatory medicine.
Citation: Weed LD. Why we need electronic diagnostic tools. J Participat Med. 2013 May 1; 5:e18.
Published: May 1, 2013.
Competing Interests: The author is the son of Larry Weed and coauthor of Medicine in Denial.
As a son of Larry Weed (LLW) and coauthor of his latest book, I appreciated Dr. Mark Graber’s reference to LLW’s “foundational work.” But LLW’s work is not well understood by Dr. Graber and many others.
Let’s focus on the second paragraph of Dr. Graber’s comment. There he “would just take issue with the suggestion for a physician extender to gather key data from a patient’s history and physical exam.” His concept is that the history and physical should be “strongly guided by the initial diagnostic hypothesis the clinician generates.” He suggests that physicians handle the process “consistently well” because “the MD has had 7+ years of training and is licensed to diagnose.”
There is a huge disconnect between this statement and the reality of medical practice. As Dr. Graber knows better than most, the reality is that licensed physicians regularly miss recognizable diagnoses.
LLW argues that such diagnostic failure is inherent in the accepted practice that Dr. Graber describes: relying on the clinician’s “initial diagnostic hypothesis” to guide the history and physical. This accepted practice demands more information processing than the human mind is capable of delivering. Physicians are blinded to this reality by a self-serving professional dogma, a faith that medical training somehow renders them capable of matching detailed patient data with vast medical knowledge.
That matching process exceeds the capacities of the human mind. As a coping mechanism, physicians quickly jump to conclusions (“initial diagnostic hypotheses”). But that exercise of “clinical judgment” introduces all the cognitive vulnerabilities that the human mind is heir to. Rather than being subjected to those vulnerabilities, patients need protection against them. The only protection is to enforce high standards of care for managing clinical information (data and knowledge), by requiring use of electronic tools designed to implement those standards. Without standards and tools external to the physician’s mind, the process of data collection and analysis will never be trustworthy.
In contrast, with the right standards and tools, initial data collection and analysis become highly organized, meticulous, and transparent. Once that foundation is laid, it may then be supplemented with judgments from the practitioner — and from the patient — about the data collected and additional data or hypotheses they believe relevant. This initial data collection and analysis must then be followed by highly organized followup processes. These involve careful problem definition, planning, execution, feedback, and corrective action over time, all documented under strict standards of care for medical record keeping. These principles relate not just to the diagnostic process but to medical decision making generally.
The need for external standards and tools would be obvious to everyone if non-physician practitioners and patients were the ones who chose the relevant data points and connected them with medical knowledge. But when physicians are involved, we let them rely on whatever “initial diagnostic hypothesis” comes to mind. Somehow we have all been socialized to believe that physician training makes this lack of discipline acceptable.
For a comprehensive discussion, see LLW’s 2011 book, Medicine in Denial, cited in Terry Graedon’s editorial. (The book’s table of contents, overview, and introduction are available here.) Readers concerned with the diagnostic process would be especially interested in Part II.A of the book, which is a detailed case study in diagnostic error, and Part IV, which presents standards and tools designed to bring order and accountability to patient data collection and analysis. For discussion especially relevant to Dr. Graber’s comment, see pp. 26-27, 43-45, 58-61, 82-86, 98-101, 136-37, and 147-52 of the book.
Copyright: © 2013 Lincoln Weed. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the author, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.