How good a doctor do you need to be?BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e7858 (Published 21 November 2012) Cite this as: BMJ 2012;345:e7858
All rapid responses
I am responding to the rapid response posted by Jason Maude, CEO and Founder of Isabel Healthcare (which produces a diagnosis checklist system), who raised the issue if the doctor should be considered negligent if he/she failed to use a readily available and validated tool to help diagnosis.
For your attention, I need to point out a few key points listed in the main article "How good a doctor do you need to be?"
1. Bolam case uses the practice of medicine with reference to responsible body of medical practitioner as benchmark
2. Bolitho case says the judge will be entitled to choose between two bodies of expert opinion and to reject an opinion which is 'logically indefensible' in the judge's opinion.
3. Bailey case clarify the idea that where "but for" uncertainty in whether the defendent materially increased the risk of harm, the relaxation of the burden to prove sufficient causal connection to be liable in negligence
I am not aware of any tool that conclusively gives the diagnosis of a condition suffered by an individual. Medical science and evidence changes often enough and in spite of evidence-based medicine, still requires a consensus from expert specialists to regularly update the latest guidelines and diagnostic criteria.
I had reviewed your website and tested the sample page but not your actual product. I do not find it more helpful at all. Your tool listed no lest than 34 differential diagnoses for a young adult male (17 - 29 yrs) who travelled North America with symptoms of abdominal pain, arthritis, hematuria, elevated ESR and leukoscytosis, including Diverticulosis, osteomyelitis/septic arthritis and Endocarditis.
Frankly speaking if I just wanted a long differential diagnosis list I just use any internet search engine. With a very long list, I am sure one of the possible diagnosis will fit 99% of all patients with that symptom combination.
As a result, I will not find myself in negligence for not using your tool. However I am worried about how you "validate" your tool. Testimonials from doctors are not vigorous validation.
A doctor who is well taught and learnt the lessons from medical school, done the clerkship and know how to use general internet tools or books to cover the gap he/she is aware of, will not find your tool helpful, in fact it distracts the user from the main business of medical care now, by ordering unnecessary investigations.
Excluding the field of oncology, the age of diagnosis and (most of the) treatment has arrived for a long time. Most of the patients do not have problems in diagnosis or deciding which treatment they need; it is actually getting the treatment itself in the era of managed care or limited health care resources.
Competing interests: I am a medical doctor
I am responding to Dr Shyan Goh's response to my previous rapid response.
First of all my question was a more general one about when it might be considered negligent not to use clinical decision support tools rather than about the specifics of my own company's tool.
It would be more meaningful if Dr Goh had tested the tool itself with a range of cases than basing her judgement on just one sample case. The tool initially returns a good list of 10 possible diagnoses with the time sensitive "don't miss" diagnoses highlighted. If the clinician wants a longer list then he can ‘view all’ and will then be shown all the 34 as mentioned. A search in Google with the same clinical features returned 637,000 results! Readers may recall a study looking at Google as a diagnostic tool where it found an accuracy rate of 50% even after the clinicians had gone through several intermediate steps. An independent study of Isabel, under more realistic conditions, found an accuracy rate of 96%.
I am a little concerned at Dr Goh’s willingness to use ‘any internet search engine’ to help her with a differential diagnosis when these engines are essentially tools to search everything and are not designed to generate a differential diagnosis. Their results are skewed on a continual basis by new content that is added.
We certainly do not regard testimonials from doctors as validation of our tool although a very useful adjunct. Over the last 10 years there have been many papers published (over 30) covering the studies looking at Isabel. Dr Goh is most welcome to read most of them from this link: http://www.isabelhealthcare.com/home/peer/new1
Dr Goh’s assertion that a doctor who is well taught will not find the tool useful and will get distracted by ordering unnecessary investigations is not bourne out in practice. We have many very experienced clinicians who find the system invaluable and some cases where they tell us that it saved a patient’s life as they had not thought of a diagnosis that was prominently suggested. In many cases these are wise and forward thinking clinicians who realise the folly of relying on their memory alone and are only too happy to use tools that can help. So far, we have also not found clinicians ordering tests for every diagnosis suggested and, in fact, increasingly they are using the tool to help them do the thinking before ordering tests, thereby decreasing the amount of inappropriate tests ordered.
I would encourage Dr Goh and others to read the research on diagnosis errors to see why these tools should be used routinely. Even if most of the patients don’t have issues with getting a timely and correct diagnosis, an awful lot do. Peter Pronovost and colleagues estimated that 40,000-80,000 people die from misdiagnosis alone in the US and, speaking at the recent Diagnostic Error in Medicine conference, said he now thought that this was an underestimate.
Competing interests: Founder of Isabel Healthcare
One aspect that I haven't yet seen tested in medicine is at what point would a doctor be considered negligent if he or she hadn't used a readily available and validated tool that, if used, could have changed the patient's outcome significantly? It may actually be the institution that employed the doctor that should be found culpable for not providing its clinicians with the necessary tools to do the job properly.
I am thinking, in particular, of the many modern clinical decision support or information tools that are now available but often either not available to or used by the clinician.
My own company produces a diagnosis checklist system which is validated, has been on the market for many years and is now even available as an app for as little as £1.99 that could save many patients from a delayed diagnosis. When could a patient reasonably expect a clinician to be considered negligent for not using these tools?
Competing interests: CEO and Founder of Isabel Healthcare which produces a diagnosis checklist system