For doctors, diagnosing gets a technological boost

For doctors, diagnosing gets a technological boost


By Andrew B. Shurtleff for USA TODAY
Sept. 7, 2007


Stephen Borowitz of the University of Virginia Medical Center uses Isabel, which helps doctors with difficult diagnoses.

Stephen Borowitz of the University of Virginia Medical Center uses Isabel, which helps doctors with difficult diagnoses.

"One
of the things I try to model for my residents is that I’m trying to
learn new things even though I’ve been doing this for a long time."

—Pediatrician Stephen Borowitz

Pediatrician Stephen Borowitz was walking the
floors of the University of Virginia Children’s Hospital with his
residents when he was presented with an unusual case.

The patient was a boy who was very ill with a
severe childhood disease called hemorrhagic shock and encephalopathy
syndrome. Borowitz says the boy had significant neurological damage and
was fed through an intravenous feeding tube.

The immediate problem was that he had a fever.
But he was showing other symptoms that didn’t match his condition. "He
had developed diarrhea, which is extremely unusual for him, and he
seemed uncomfortable," Borowitz says.

Borowitz worried that the culprit was a
bloodstream infection, a typical problem with patients with intravenous
feeding tubes. But something still didn’t seem right.

So Borowitz and his residents consulted Isabel,
a Web-based medical technology that generates a list of possible
diagnoses based on the patients’ symptoms.

"I put all his symptoms into Isabel and it came
up with a number of ideas," he says. "One of them was gallbladder
disease, which I probably should have thought of, but I didn’t."

 

INTERACTIVE GRAPHIC: How Isabel works

An ultrasound was ordered, and gallbladder
disease was indeed the problem, and it may not have been related to the
boy’s pre-existing condition or his feeding tube.

Misdiagnoses are common

According to a 2003 Journal of the American Medical Association
review of autopsy studies, doctors misdiagnose 8% to 24% of the time.
Cognitive errors, such as latching onto a diagnosis that seems the most
likely without considering other possibilities — which experts call
"anchoring" — are among many root causes, according to Jerome Groopman,
chairman of experimental medicine at Harvard University and author of
the book How Doctors Think.

The solution for some is technology. Doctors are
increasingly using the Internet, even search programs as basic as
Google, when they’re stumped, according to "Googling for a Diagnosis,"
a British Medical Journal study last year.

Although Isabel is used in only 18 hospitals,
interest in similar decision-support systems is growing in the medical
community, according to the American Medical Informatics Association.
Priced at around $50,000 a year for a typical 300 bed hospital, Isabel
is considered a robust tool, highly rated by the Healthcare Information
and Management Systems Society.

"One of the things I try to model for my
residents is that I’m trying to learn new things even though I’ve been
doing this for a long time," Borowitz says.

"It’s the acknowledgment that I’m fallible and I need to use all the tools I can to make sure I’m giving the best care."

When doctors diagnose, they "match" a patient’s
symptoms against the patterns of several likely diseases, narrowing
down the list as they go, according to Lawrence Weed, professor
emeritus of medicine at the University of Vermont. This decision-making
process, known as combinatorial thinking, involves juggling too much
information for it to be successful without the aid of technology, Weed
says.

"The mind can’t possibly deal with the
complexity of the problem that a patient presents," Weed says. "What if
you said, ‘Let’s give (doctors) eight years of geography at Harvard and
then let them to drive across the country without a map’?"

Weed developed Problem Knowledge Couplers — a
technology that "couples" patient symptoms with relevant medical
literature. With Couplers, patients can enter their symptom information
into the Web-based tool and walk through the medical knowledge with
their doctor. About 50 private employers now provide access to Couplers.

A correct diagnosis can hinge on a doctor
recalling a crucial piece of information — one he or she may have
learned years ago in medical school or read in a journal months ago,
says physician and Isabel developer Joseph Britto. Similar to Couplers,
Isabel allows doctors to "click through" medical knowledge related to a
possible diagnosis. Isabel, Britto says, was developed to help doctors
reduce errors by lightening the "burden of memory."

"In the traditional medical environment, people
expect you to know everything," says Napoleon Knight, a physician at
the Carle Foundation Hospital near Chicago, who uses Isabel in the
emergency room to help diagnose his patients. "It can be difficult
sometimes to keep all that knowledge right at the top of your brain so
you can pull it out when you really need it."

‘Cookbook’ medicine?

Groopman, however, fears that placing too much emphasis on technology will take the spotlight off clinical judgment.

"With these cookbook-type recipes for diagnosis
and treatment, the risk is that’s it’s garbage in, garbage out,"
Groopman says. "They’re only as good as the physician who is
identifying what the key symptom or key finding is about the patient."

Many doctors who use Isabel argue that
technology doesn’t supersede individual judgment but rather acts as an
aid in the decision-making process.

"Certainly it will never take the place of
judgment," Knight says. "There’s still a lot that you learn about an
individual patient just by walking into the room and seeing the look on
their face, or by placing your hand on their forehead."

NOTE: The original story placed Isabel’s cost at $750. It is $50,000, as now noted in the text.

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