Читать книгу How to Get the Right Diagnosis - Randolph H. Pherson - Страница 15
ОглавлениеFive Techniques to Spur a Correct Diagnosis
During my five-year odyssey, I noticed a constant tension between the temptation for doctors to start treating the illness versus taking the necessary time to diagnose it. Usually, the default was to treat. In general, this strategy usually turns out to be successful because of the following:
1.In a high percentage of cases, the human body will eventually cure itself. If you visit the doctor, a treatment is usually prescribed, but, at best, it may only be expediting the recovery process.
2.Most illnesses can be treated successfully with just one or two treatments.
But what if the problem is more complicated? Given such strong incentives to treat and not diagnose, many of us who have unusual and hard-to-diagnose conditions become frustrated. Our lives become littered with unending visits to doctors’ offices, myriads of tests, and a series of unsuccessful treatments. If we die, no one usually will notice that our illnesses were undiagnosed. Our families are grieving; they already knew there was a problem and usually feel impelled to just move on.
What tools or techniques are available to this minority of undiagnosed patients, whom I call the forgotten “5 percent?” How can they get the attention they deserve? This chapter presents six Structured Analytic Techniques (SATs) they can employ to focus more attention on the need for a diagnosis.2 It describes when the techniques are most useful, what cognitive biases they help to correct, and how they were—or could have been—used in my case. The book also contains examples of how these SATs were used correctly with good results, as well as examples when they were not applied—with serious negative consequences for the patient.
SATs were developed in the late 1990s to provide more rigorous, transparent, and collaborative methods for analyzing a problem, resolving differences, innovating solutions, and anticipating the future. The techniques have proven highly effective in supporting the analytic process in the intelligence community as well as in the corporate world.3 They are a subset of a variety of practices in the intelligence community that can—and have been—adapted to the medical profession to reduce errors and improve the quality of health care (see Figure 6).
SATs came into prominence following the terrorist attacks on September 11, 2001, and the flawed 2002 National Intelligence Estimate on weapons of mass destruction in Iraq as a way to improve the overall quality of analysis in the US Intelligence Community. Over the years, use of the techniques has spread to other parts of the US government, foreign intelligence services, major corporations, and academia.
The techniques have universal value and utility. Analysis of Competing Hypotheses (ACH), for example, is similar to differential diagnosis in the medical profession.
The following key practices or concepts in intelligence analysis have the potential to help medical professionals reduce error rates:
• Recognize how mental mindsets and past experiences can bias a diagnosis (Cognitive Bias and Intuitive Traps).
• Develop more than one explanation for an illness during the initial diagnosis (Multiple Hypothesis Generation).
• Challenge preconceived notions generated by a patient’s appearance, age, or race (Key Assumptions Check).
• Focus on disconfirming evidence to quickly eliminate incorrect diagnoses (Analysis of Competing Hypotheses).
• Seek out and value the opinions of others working the case (Coordination and Peer Review).
• Know when to expect deception (Deception Detection).
Figure 6. Intelligence Tradecraft for Medicine
In this chapter, we discuss how you can leverage five SATs to gain more knowledge about your condition while helping your doctor make a correct diagnosis. The six techniques are:
1.Multiple Hypothesis Generation
2.Analysis of Competing Hypotheses
3.Indicators Generation
4.Key Assumptions Check
5.Premortem Analysis
6.Structured Self-Critique
Step-by-step instructions on how to use these techniques can be found in Appendices A-F which contain additional information on when to use them, the value added, their relationship to other techniques, and potential pitfalls to avoid.4
Multiple Hypothesis Generation: What Is the Range of Explanations for My Condition?
Instead of telling you X is the problem, let’s explore several options.
In his book, How Doctors Think, Dr. Jerome Groopman argues that the practice of considering alternative explanations for a medical problem is one of the strongest safeguards against making cognitive errors.5 He quotes one of his colleagues as saying, “I learned to always hold back [and avoid jumping to a conclusion], to make sure that, even when I think I have the answer, to generate a short list of alternatives.”
Multiple Hypothesis Generation is a technique for generating multiple alternatives for explaining a particular issue, activity, or behavior. It is a key technique in the analyst’s toolkit and is particularly useful when many factors are involved, a high degree of uncertainty exists regarding the diagnosis, and your doctors and/or nurses hold different views.
The technique helps you, your family, and your doctors avoid—or at least mitigate the power of—several analytic traps, including:
• Coming to premature closure.
• Being overly influenced by first impressions.
• Seizing on the first diagnosis or procedure that looks “good enough.”
• Focusing on too narrow a range of alternatives.
• Selecting an explanation that replicates a past success or avoids a previous error.
The value of first considering multiple diagnoses can be demonstrated with the case of dementia. Dementia can be caused by a wide variety of illnesses, injuries, and other factors. Narrowing down the type of dementia is critical to successful treatment. Individuals with Parkinson’s disease, for example, may have symptoms similar to other types of dementia, but the treatment could be vastly different. The symptoms of dementia can make it hard to pin down the specific type of the disease a patient has.
Failing to identify the type of dementia can result in poor treatment outcomes due to paradoxical reactions (when a medication causes an unexpectedly opposite reaction to what was intended). For example, individuals with a certain type of dementia called Lewy body typically have a paradoxical reaction to benzodiazepine medications such as Valium. When an agitated patient with Lewy body dementia is prescribed a benzodiazepine medication (which is a typical first-line medication for agitation), instead of calming the patient, the effect is to increase the level of agitation. For these reasons, an attentive doctor should first consider a range of possible forms of dementia and then narrow down the diagnosis to avoid prescribing an incorrect treatment.
