Rockin’ Pneumonia or the Boogie Woogie Flu? Thoughts on the IOM Report on Diagnosis Errors

I just finished reading a book called The History of Rock’n’Roll In Ten Songs by Greil Marcus. I am a big music fan and I like the premise of this book: that the history of rock’n’roll music has been told wrong. Marcus says that this story has always been told from a conventional wisdom sort of place where chronology is king, but that this approach denies the power of certain pivotal songs, which are themselves the propellant that moves the genre forward. Marcus’ concept is that it is not certain bands or the passage of time that tell you how rock’n’roll has developed, but individual songs,. He suggests that you really have to listen to the musician’s words and sounds to see how music’s history has and will unfold.

For reasons that may be obvious only to me, this premise sent me straight to reflecting about the most recent Institute of Medicine report released two weeks ago and entitled “Improving Diagnosis in Health Care.” This report tells the story of our healthcare systems’ ongoing failure to properly diagnose patients. Among the findings were these, cited in a US News article about the report:

• About 5 percent of adults who seek outpatient care annually suffer a delayed or wrong diagnosis.
• Postmortem research suggests that diagnostic errors are implicated in one of every 10 patient deaths. Not every death is scrutinized, however, so the findings can’t be generalized to all hospital patients.
• Chart reviews indicate that diagnostic errors account for up to 17 percent of hospital adverse events.
• Diagnostic errors are the principle cause of paid malpractice claims and are almost twice as likely to end in a patient’s death than claims for other medical mishaps. They also represent the biggest share of total payments.

All I have to say to that is Holy Guacamole Batman!  That is really scary.

Here’s how I made the connection back to my history of rock ‘n’ roll book: clinicians take the patient history, look for recognizable indicators and match them to the patterns they have in their heads from customary approaches past, and then send the patient down the wrong treatment road. In other words, too often our medical community has come to rely too much on misleading chronology and what has come to be conventional medical truth as opposed to really listening to the patient to see how their personal history has and will unfold and affect the entire road ahead.

The failure to diagnose patients properly is a national tragedy that surpasses the problem brought to light by the 1999 IOM report “To Err is Human,” which was about the medical mistakes made after patients are admitted to the hospital. But by failing to diagnose people correctly to begin with, an entire cascade of medical mistakes are set in motion which far too often result in bad or tragic outcomes. If Greil Marcus, who wrote the rock’n’roll book, had written this IOM report, it would be titled: Not sure if it’s rockin’ pneumonia or the boogie woogie flu, but what the hell, let’s play through.

I particularly liked this passage from the Marcus book, which seems to me to be highly relevant to any field, music or healthcare or anything that can and should evolve:

“Whole intellectual industries are devoted to proving that there is nothing new under the sun, that everything comes from something else—and to such a degree that one can never tell when one things turns into something else. But it is this moment when something appears as if out of nowhere, when a work of art carries within itself the thrill of invention, of discovery, that is worth listening for. It’s that moment when a song or a performance is its own manifesto, issuing its own demands on life in its own, new language—which though the charge of novelty is its essence, is immediately grasped by any number of people who will swear they never heard anything like it before—that speaks.”

The always compelling Atul Gawande wrote similarly about this concept in his New Yorker piece, Desperate Measures, where he writes about legendary physicians who practiced to the beat of their own drummer, convinced they had invented a new way and, ultimately finding that they did in fact change the course of medicine, by hearing something new in their heads that denied what always was. These clinicians’ decisions to play on despite early failure ultimately led to the re-writing of conventional wisdom about surgery, medication use, and other approaches to treatment that are now commonly accepted today and set the stage to change the course of medical history

In the diagnostics world we are now seeing some new thinking that may radicalize and hopefully will change the course of how medicine is performed today. We are witnessing dramatic evolution in the use of genomics, microbiomics, and especially patient-reported data, all fields which once were thought either impossible (in the case of the former) or uncompelling (in the case of the latter). We are seeing breakthroughs in home testing that may render traditional lab models obsolete.

And across all of these approaches we are watching the emergence of data analytics that may make the way we perform diagnosis a totally new endeavor. There is an increasing recognition that not even the most brilliant doctor can know everything about a patient or keep every possible diagnosis or pathway in his or her head. Educated and experienced as one may be, it is too easy to see one’s patient through experience-colored glasses when one’s own experience may not hold the answer to the question. History is not always derived from the past but sometimes from new breakthroughs that change its course.

Broad-based analytics platforms can eat all of the data that there is about people–their medical history, others’ medical histories, clinical and disease pathways, patient’s own experiential reports both input and blue-toothed–and find their way to new hypotheses. Certainly this is the promise promoted by IBM’s Watson and so many others’ products: by being essentially all-knowing and without bias, diagnosis can become patient-centric and personalized in a way it has never been before. Of course the inputs are not pure—pathways and algorithms are themselves devised with the biases of their creators—but the sheer volume of data and knowledge that can be synthesized, analyzed and understood through these platforms could make a meaningful difference in those diagnosis mistakes if we can just find a way to put the tool in the hands of the clinician when they are standing face to face with the patient. This must be a just-in-time and real-time endeavor.

Marcus picks out “Money Changes Everything” as one of the top 10 songs that changed rock and roll, and it’s an apt theme song for medicine as well, for better or for worse. Those who bear financial risk, particularly those new to that endeavor, are starting to hear the siren song that analytics can play for them. As our government and other payers start paying not just for “performance,” whatever that is, but for “outcome,” aka: right diagnosis, right treatment (as defined by both patient and clinician), right result (also defined by both patient and clinician), right cost, we will see more and more adoption of these tools.

By the time our system becomes truly financially aligned, and that may take a while, I expect the tools will catch up with the beat of patient care. But for now, patient beware. The great jazz musician Charlie Parker once said, “Music is your own experience, your thoughts, your wisdom.” In my view, you must look upon your health status the same way. Don’t cede the role of conductor to others; be an active player in writing and defining your medical history, even if it does not tell the story others expect.