The need for a careful and thoroughhistory and how to obtain onewww.MarylandClinicalDiagnostics.comCOURSE 2Nelson Hendler,...
Concepts for Diagnosis• A diagnosis allows “predictive analytics.”• “Predictive analytics” is essentially patternrecogniti...
Evidence Based Medicine• “Outcome studies” or “evidence based medicine”measure how good your “predictive analytics”were.• ...
Pattern Recognition and OutcomeStudies lead to Predictive Analytics• My car won’t start, and the lights were left onoverni...
The value of a thorough historyIn Israel, a swallowing disorder questionnaire couldpredict findings on oral physical exami...
Various Educational InstitutionsRecognize a Thorough Historyprovides Proper Diagnosis• The value of a diagnosis is ---• It...
Training to Take a Thorough HistoryThis study evaluated the impact of a training program incommunications skills on subseq...
Teaching History Taking SkillsSince clinical training often fails to equip medical students with essentialhistory-taking s...
Teaching History Taking Skills• Communication is an important component of patient care. Traditionally,communication in me...
Teaching History Taking Skills• Ones efficiency and effectiveness in communication can be improved through training,but it...
Teaching History Taking Skills• Ensuring key issues are verbalized openly is fundamental to effective patient-doctor commu...
Teaching History Taking Skills• Recognizing that skilled history-taking is in danger ofbecoming a lost art, the American B...
Teaching History Taking Skills• Though most medical schools administer comprehensive clinical skillsassessments to identif...
Conclusion-Teaching History Taking• Time consuming to teach and learn• Labor intensive to teach and learn• Without trainin...
How failure of taking a careful historyinterferes with making a diagnosis• If a patient complains of pain in their thumb, ...
Real-life Problems with Taking aThorough History• Not enough time to take a history• Interruptions by phone, or staff• Los...
Specific Problems with Chronic Pain• Patients focus on the severity of the pain,which is of no diagnostics value, since pa...
Interpretation of the Answers• A throbbing, pounding pain is indicative of avascular problem.• Numbness is indicative of s...
www.MarylandClinicalDiagnostics.comDiagnostic Paradigm• Research has shown that 40%-80% of chronic painpatients are misdia...
Diagnostic Paradigm• The Diagnostic Paradigm test(www.MarylandClinicalDiagnostics.com) has a96% correlation with Johns Hop...
Diagnostic Paradigm TestDevelopment• The Diagnostic Paradigm is based on datacollected over 17 years.• After a retrospecti...
The Diagnostic Paradigm &Treatment Algorithm• The test consists of 72 questions with 2008possible answers.• The test takes...
Evidence Based Medicine-Outcome Studies• The value of the test from the team at Johns Hopkins Hospital isdocumented by out...
Outcome Studies• The www.MarylandClinicalDiagnostics.com methodsresulted in improved medical care and cost savings,ranging...
Treatment Algorithm• Rank ordered test based on least invasive, leastexpensive testing, increasing in expense andcomplexit...
Bayesian versus Boolean Logic• Experience (Bayesian) versus binary thinking• Boolean logic is binary- “on-off,” or “yes-no...
Bayesian Logic• In Bayesian logic:• Each outcome gets a weighted answer• Is the tire flat? Yes-No.• Have you has a flat in...
Ease of Use of Test versus Training• Training for medical students and residents isexpensive and time consuming• Many phys...
CPT Codes for billing for the test• Use the three following codes to reportservices for the Diagnostic Paradigm andTreatme...
Authors of Missed DiagnosesPapers, and Diagnostic Paradigm• Donlin Long, MD, Ph.D. former chairman of neurosurgery Johns H...
Contact Information• Nelson Hendler, MD, MS, CEO• Maryland Clinical Diagnostics• Former Assistant Professor of Neurosurger...
Upcoming SlideShare
Loading in …5
×

Course 2 the need for a careful and thorough history

520 views

Published on

The medical literature reports that 40%-80% of chronic pain patients are misdiagnosed. Clearly, misdiagnosis leads to ordering the wrong tests, and thereby obtaining an incorrect diagnosis, or overlooking a diagnosis totally, which results in mistreatment. Many reports in the medical literature indicate the best way to get an accurate diagnosis, is to obtain a complete and thorough history. However, this is a time consuming process, and most physicians don’t spend the needed time with a patient. Therefore, a team of doctors from Johns Hopkins Hospital developed a 72 question test, with 2008 possible answers, available over the Internet. When a patient completes the questionnaire, diagnoses are returned within 5 minutes. These diagnoses have a 96% correlation with diagnoses of Johns Hopkins Hospital doctors. This is the highest level of accuracy of any expert system available. The efficacy of this approach is proven by outcome studies, which prove that this approach results in a far higher return to work rate and reduced use of medication and doctors visits, when compared to other techniques. This is similar to the techniques used by Johns Hopkins Hospital to reduce their workers compensation payments by 54%.

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
520
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
10
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Course 2 the need for a careful and thorough history

  1. 1. The need for a careful and thoroughhistory and how to obtain onewww.MarylandClinicalDiagnostics.comCOURSE 2Nelson Hendler, MD, MSFormer Assistant Professor of NeurosurgeryJohns Hopkins University School of MedicinePast president-American Academy of Pain Management
  2. 2. Concepts for Diagnosis• A diagnosis allows “predictive analytics.”• “Predictive analytics” is essentially patternrecognition, i.e. recognizing a pattern ofsymptoms, or behavior, a “clusters of events,”and then predicting what else can be associatedwith these “clusters of events.”• I noticed the headlights on my car were left onover night, and the car won’t start. I should-1)add gas 2) charge the battery 3) change thesolenoid 4) get new spark plugs
  3. 3. Evidence Based Medicine• “Outcome studies” or “evidence based medicine”measure how good your “predictive analytics”were.• This is based on longitudinal studies, to determinethe accuracy of diagnosis, and if the propertreatment was selected, based on outcome, or theresults of treatment.• My car won’t start-what else is associated with it?• It just clicks-change the solenoid• Nothing happens or just whirrs- change the battery• It turns over but sputters- add gas
  4. 4. Pattern Recognition and OutcomeStudies lead to Predictive Analytics• My car won’t start, and the lights were left onovernight, and it whirrs when I turn the ignition key – acluster of symptoms, history and signs.• Based on experience, from doing a variety of treatmentsfor this condition with the associated symptoms, I knowthat charging the battery is going to produce betterresults than changing the solenoid• I charge the battery, and the car starts-Evidence Based• I can now predict what treatment works for the set ofsymptoms of a) symptom of not starting b) history oflights left on c) sign of a whirring engine
  5. 5. The value of a thorough historyIn Israel, a swallowing disorder questionnaire couldpredict findings on oral physical examination 85%ofthe time (1).In Canada, a questionnaire could predict whowould have abnormal ankle X-rays 98% of thetime (2)In the US, a questionnaire could predict whichpatient with back or neck pain would havemedical test abnormalities 95% of the time (3)(1) Cohen JT, Manor Y. Swallowing disturbance questionnaire for detecting dysphagia. Laryngoscope. 2011Jul;121(7):1383-7(2) Stiell, IG, Greenberg, GH, McKnight, RD, Nair, RC, McDowell, I., Reardon, F, Stewart, JP, Maloney, J.: Decision rulesfor the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA, March 3, 269(9):1127-32, 1993(3) Hendler, N. and Baker, A., An Internet questionnaire to predict the presence or absence of organic pathology inchronic back, neck and limb pain patients, Pan Arab Journal of Neurosurgery, Vol. 12, No. 1, pp: 15-24, April,2008.
  6. 6. Various Educational InstitutionsRecognize a Thorough Historyprovides Proper Diagnosis• The value of a diagnosis is ---• It allows a physician to explain symptoms and signs• It determines the source of the illness- thepathophysiology• Once the pathophysiology is established, from thediagnosis, the physician can then select proper tests toconfirm the diagnosis• With proper confirmation, specific treatments, based onexperience, can be used which give a predicted
  7. 7. Training to Take a Thorough HistoryThis study evaluated the impact of a training program incommunications skills on subsequent diagnostic efficiency.Videotaped history-taking interviews conducted by groups ofspecially trained and control groups of students were rated fortheir diagnostic efficiency by two medical practitioners. Students inthe trained group had shown greatly increased skills in interviewingand interpersonal effectiveness as a result of their training. Acomparison of ratings given by the two experimentally naive,independent observers revealed that trained students weresignificantly better at eliciting full, relevant data from patients--they were diagnostically more efficient, but took no longer thantheir control group counterparts to elicit the information. Furtherresearch with the medical interview rating scale will clarify theskills required of medical students in interviewing and diagnosisand facilitate remedial training for students who show poorinterview skills.Evans BJ, Stanley RO, Mestrovic R, Rose L., Effects of communication skills training on students diagnosticefficiency, Med Educ. 1991 Nov;25(6):517-26.
  8. 8. Teaching History Taking SkillsSince clinical training often fails to equip medical students with essentialhistory-taking skills, more effective teaching methods required to bedeveloped. As previous work had suggested that training which includedtelevised demonstrations of history-taking and practice with simulatedpatients might be superior to traditional methods, it was decided toevaluate this experimentally. Thirty students beginning the Oxford ClinicalCourse were randomly selected and allocated to a traditional or one of twoexperimental courses. Both experimental courses used television andsimulation but differed in the way the history-taking demonstrations werepresented. After completing these courses, each student was asked to takea history from a simulated patient. Rating of the videotapes of theseinterviews showed that the two experimental groups obtained much moreinformation and used many more of the required skills than studentsassigned to the traditional course. The experimental students were alsorated more favourably by the simulators and recorded more data in theircase histories. It is concluded that these short courses were practical, veryeffective, and could be augmented by a self-teaching programme in history-taking skills.Maguire GP, Clarke D, Jolley B. An experimental comparison of three courses in history-taking skills for medicalstudents, Med Educ. 1977 May;11(3):175-82.
  9. 9. Teaching History Taking Skills• Communication is an important component of patient care. Traditionally,communication in medical school curricula was incorporated informally as part ofrounds and faculty feedback, but without a specific or intense focus on skills ofcommunicating per se. The reliability and consistency of this teaching method leftgaps, which are currently getting increased attention from medical schools andaccreditation organizations. There is also increased interest in researching patient-doctor communication and recognizing the need to teach and measure this specificclinical skill. In 1999, the Accreditation of Council for Graduate Medical Educationimplemented a requirement for accreditation for residency programs that focuseson "interpersonal and communications skills that result in effective informationexchange and teaming with patients, their families, and other healthprofessionals." The National Board of Medical Examiners, Federation of StateMedical Boards. and the Educational Commission for Foreign Medical Graduateshave proposed an examination between the. third and fourth year of medicalschool that "requires students to demonstrate they can gather information frompatients, perform a physical examination, and communicate their findings topatients and colleagues" using standardized patients.• Teutsch C. Patient-doctor communication. Med Clin North Am. 2003Sep;87(5):1115-45.
  10. 10. Teaching History Taking Skills• Ones efficiency and effectiveness in communication can be improved through training,but it is unlikely that any future advances will negate the need and value ofcompassionate and empathetic two-way communication between clinician and patient.The published literature also expresses belief in the essential role of communication. "Ithas long been recognized that difficulties in the effective delivery of health care canarise from problems in communication between patient and provider rather than fromany failing in the technical aspects of medical care. Improvements in provider-patientcommunication can have beneficial effects on health outcomes". A systematic reviewof randomized clinical trials and analytic studies of physician-patient communicationconfirmed a positive influence of quality communication on health outcomes.Continuing research in this arena is important. For a successful and humanisticencounter at an office visit, one needs to be sure that the patients key concerns havebeen directly and specifically solicited and addressed. To be effective, the clinician mustgain an understanding of the patients perspective on his or her illness. Patient concernscan be wide ranging, including fear of death, mutilation, disability; ominous attributionto pain symptoms; distrust of the medical profession; concern about loss of wholeness,role, status, or independence; denial of reality of medical problems; grief; fear of leavinghome; and other uniquely personal issues. Patient values, cultures, and preferencesneed to be explored. Gender is another element that needs to be taken intoconsideration.• Teutsch C. Patient-doctor communication. Med Clin North Am. 2003 Sep;87(5):1115-45.
  11. 11. Teaching History Taking Skills• Ensuring key issues are verbalized openly is fundamental to effective patient-doctor communication. The clinician should be careful not to be judgmental orscolding because this may rapidly close down communication. Sometimes thepatient gains therapeutic benefit just from venting concerns in a safeenvironment with a caring clinician. Appropriate reassurance or pragmaticsuggestions to help with problem solving and setting up a structured plan ofaction may be an important part of the patient care that is required. Counselingaround unhealthy or risky behaviors is an important communication skill thatshould be part of health care visits. Understanding the psychology of behavioralchange and establishing a systematic framework for such interventions, whichincludes the five As of patient counseling (assess, advise, agree, assist, andarrange) are steps toward ensuring effective patient-doctor communication.Historically in medicine, there was a paternalistic approach to deciding whatshould be done for a patient: the physician knew best and the patient acceptedthe recommendation without question. This era is ending, being replaced withconsumerism and the movement toward shared decision-making. Patients areadvising each other to "educate yourself and ask questions". Patient satisfactionwith their care, rests heavily on how successfully this transition is accomplished.Ready access to quality information and thoughtful patient-doctor discussions isat the fulcrum of this revolution.Teutsch C. Patient-doctor communication. Med Clin North Am. 2003 Sep;87(5):1115-45.
  12. 12. Teaching History Taking Skills• Recognizing that skilled history-taking is in danger ofbecoming a lost art, the American Board of Internal Medicinecalls attention to the urgent need for internal medicineresidency programs to ensure that these skills are taught andassessed. Although the Boards certification examinationcontains standardized items that test the physicians ability touse information from a patients medical history, the writtenexamination cannot assess the physicians ability to elicit thathistory. The Board believes that history-taking skills willbecome even more crucial as health care delivery changes,requiring more cost efficiency without sacrificing quality. Byhighlighting the skills of effective history-taking and strategiesfor assessment, the Board offers specific recommendationsfor its promotion as a key element of quality patient care.Schechter GP, Blank LL, Godwin HA Jr, LaCombe MA, Novack DH, Rosse WF.Refocusing on history-taking skills during internal medicine training. Am JMed. 1996 Aug;101(2):210-16
  13. 13. Teaching History Taking Skills• Though most medical schools administer comprehensive clinical skillsassessments to identify students who have not achieved competence, thetypes of problems uncovered by these exams have not beencharacterized. METHOD: The authors interviewed 33 individualsresponsible for remediation after their schools comprehensiveassessments, to explore their experience with the problems studentsdemonstrate and strategies for and success with remediation. RESULTS:Respondents perceived that technique problems in history taking andphysical examination were readily correctable, but that poor performanceresulting from inadequate knowledge or poor clinical reasoning ability wasmore difficult to ameliorate. Interpersonal skill deficiencies, which oftenmanifested as detachment from the patient, and professionalismproblems attributed to lack of insight, were most refractory toremediation. CONCLUSIONS: Poor performance in comprehensiveassessments often indicates underlying deficiencies in cognitive ability,communication skills, or professionalism. The challenge of remediatingthese deficiencies late in medical school calls for earlier identification andintervention.Hauer KE, Teherani A, Kerr KM, OSullivan PS, Irby DM. Student performance problems in medicalschool clinical skills assessments. Acad Med. 2007 Oct;82(10 Suppl):S69-72
  14. 14. Conclusion-Teaching History Taking• Time consuming to teach and learn• Labor intensive to teach and learn• Without training, lots of inter-rater variability• Doctors are rushed, so less likely to spend time• Insurance doesn’t reward long time with a patient• Failure to take adequate or accurate history leadsto bad medical diagnosis• Variables include not only the skills of the doctors,but the communication skills of the patient• Doctors tend to rely on tests rather than history
  15. 15. How failure of taking a careful historyinterferes with making a diagnosis• If a patient complains of pain in their thumb, and thedoctor takes an X-ray, and sees a vise clamped on thethumb, the diagnosis is established, and the treatment isclear..remove the vise.• If a patient complains of pain in their thumb, and thedoctor sees no broken bones or compression, on X-ray,then he doesn’t have a diagnosis nor a treatment.• But if a doctor asks “How did the pain start?” and is told“When I repetitively hit my thumb with a hammer” thenthe cause of the pain is established. The X-ray is neededonly to see if the repetitive hammer blows chipped orbroke a bone, which leads to one treatment, or if thetissue is just bruised, which leads to another treatment
  16. 16. Real-life Problems with Taking aThorough History• Not enough time to take a history• Interruptions by phone, or staff• Loss of train of thought-tired-distracted• Forgetting to ask questions• The patient has communication problems, i.e.hard of hearing, English is not the firstlanguage, fear of the doctor, notunderstanding the questions, lack ofknowledge of their body, forgetting symptoms
  17. 17. Specific Problems with Chronic Pain• Patients focus on the severity of the pain,which is of no diagnostics value, since pain is atotally subjective experience• Doctors don’t ask the right questions, becausethey are not trained in history taking fromchronic pain problems• Key questions are the location of the pain, howthe pain first occurred, the type of pain whichis felt, what makes it better, what makes itworse, and is it constant or intermittent.
  18. 18. Interpretation of the Answers• A throbbing, pounding pain is indicative of avascular problem.• Numbness is indicative of sensory nerve damage,of either compressive nature, compromisedvascular flow, or metabolic nature, such asdiabetes, or poisoning.• A constant pain predicts a compressive nature tothe cause.• An intermittent pain predicts a mechanicalcomponent to the source of the pain.• Location predicts the nerve causing the pain, etc.
  19. 19. www.MarylandClinicalDiagnostics.comDiagnostic Paradigm• Research has shown that 40%-80% of chronic painpatients are misdiagnosed(1,2,3,4,5,6,7,8,9,10,11)• 1) Dellon, A.L., Hendler, N., Hopkins, J.E.T., Karas, A.C., Campbell, J.N.: "Team Management of Patients with Diffuse Upper Extremity Complaints." Maryland Medical Journal. Vol.35, No. 10:849-852, October, 1986.• 2) Long, D., Filtzer, D., BenDebba, M., Hendler, N.: "Clinical Features of the Failed-Back Syndrome." Journal of Neurosurgery. Vol. 69, pp. 61-71, July, 1988.• 3) Hendler, N., Kozikowski, J., Schlesinger, R., Schlesinger, J.: "Diagnosis and Treatment of Muscle Tension Headaches." Pain Management. Vol. 4, No. 2:33-41, March/April, 1991.• 4) Hendler, N., Zinreich, J., Kozikowski, J.: "Three-DMCDnsional CT Validation of Physical Complaints in `Psychogenic Pain Patients." Psychosomatics. Vol. 34, No. 1:90-96,January/February, 1993.• 5) Hendler,N.,Kozikowski,J.:" Overlooked Physical Diagnoses in Chronic Pain Patients Involved in Litigation." Psychosomatics.Vol.34,No.6:494-501,November/December, 1993.• 6) Hendler,N. Kozikowski, J., Morrison, C., Sethuraman,G. "Diagnosis and Management of Sacroiliac Joint Disease." Journal of the Neuromusculoskeletal System.Vol. 3, No.4:169-174, Winter, 1995.• 7) Hendler, N., Bergson, C., Morrison, C.: "Overlooked Physical Diagnoses in Chronic Pain Patients Involved in Litigation, Part 2." Psychosomatics. Vol. 37, No.6: 509-517,November/December, 1996.• http://www.slideshare.net/DiagnoseMyPain/overlooked-diagnoses-in-chronic-pain• 8) Hendler, N.: “Differential Diagnosis of Complex Regional Pain Syndrome.” Pan Arab Journal of Neurosurgery. Oct., 2002 pp. 1-9.• http://www.slideshare.net/DiagnoseMyPain/crps-rsd-overdiagnosed-71-of-time• 9) Hendler, N. Overlooked Diagnoses in Electric Shock And Lightning Strike Survivors, Journal of Occupational and Environmental Medicine, Vol. 47, No. 8, pp. 796-805, Aug. 2005.• http://www.slideshare.net/DiagnoseMyPain/electric-shock-and-lightning-survivors-misdiagnosis• 10) Hendler, N, Murphy, ME, Romano, T. Chronic Pain Due to Thoracic Syndrome, Acromo-Clavicular Joint Syndrome, Disrupted Disc, Nerve Entrapments, Facet Syndrome, andOther Disorders Misdiagnosed as Fibromyalgia. Abstract 1086 Poster presentation, American Psychosomatic Society, Portland, Oregon, March 10-13, 2010.http://www.psychosomaticmedicine.org/misc/meetingAbstracts.shtml, page 91, 2010,• http://www.slideshare.net/DiagnoseMyPain/fibromyalgia-abstract• 11) Dellon, AL, Andronian, E, Rosson, GD, CRPS of the upper or lower extremity: surgical treatment outcomes, J. Brachial Plex Peripher Nerve Inj, Feb 20: 4 (1):1, 2009)
  20. 20. Diagnostic Paradigm• The Diagnostic Paradigm test(www.MarylandClinicalDiagnostics.com) has a96% correlation with Johns Hopkins Hospitaldoctors’ diagnoses, so the patient will get adiagnosis which is virtually similar to one froma Johns Hopkins Hospital physician (19).• 19) Hendler, N., Berzoksky, C. and Davis, R.J. Comparison ofClinical Diagnoses Versus Computerized Test Diagnoses Usingthe Mensana Clinic Diagnostic Paradigm (Expert System) forDiagnosing Chronic Pain in the Neck, Back and Limbs, PanArab Journal of Neurosurgery, pp:8-17, October, 2007.http://www.slideshare.net/DiagnoseMyPain/diagnostic-paradigm-p
  21. 21. Diagnostic Paradigm TestDevelopment• The Diagnostic Paradigm is based on datacollected over 17 years.• After a retrospective analysis of 15,000patient files and prospective testing, theDiagnostic Paradigm was developed• This is virtually impossible to replicate interms of sample size, length of dataaccumulation and expertise of the doctors.• This test is available atwww.MarylandClinicalDiagnostics.com
  22. 22. The Diagnostic Paradigm &Treatment Algorithm• The test consists of 72 questions with 2008possible answers.• The test takes 5 minutes of secretarial time toaccess the program for testing• It takes the patient 20 to 60 minutes tocomplete.• The test is available in English and Spanish• Results are available 5 minutes after the test iscompleted.
  23. 23. Evidence Based Medicine-Outcome Studies• The value of the test from the team at Johns Hopkins Hospital isdocumented by outcome studies. This is true “Evidence BasedMedicine.” As an example, most workers compensation insurancecarriers report that if a person is out of work for two years or moreafter an injury on the job, the return to work rate is less than onepercent. Using the Diagnostic Paradigm fromwww.MarylandClinicalDiagnostics.com, in a group of patients outof work for an average of 4.9 years, one clinic was able to achievea return to work rate of 19.5% for workers compensation patients,62.5% for auto accident patients, and in both groups, a 90%reduction in the use of narcotic medication, and a 45% reductionin doctor visits (25,26).• 25) Hendler, N.: "Validating and Treating the Complaint of Chronic Back Pain: The Mensana Clinic Approach." Clinical Neurosurgery. Vol. 35,Chap. 20:385-397, eds. Black, P., Alexander, E., Barrow, D., et. al., Williams and Wilkins, Baltimore, 1988.• http://www.slideshare.net/DiagnoseMyPain/validating-the-complaint-of-pain-13871037• 26) Talo, S., Hendler, N., Brodie, J.: "Effects of Active and Completed Litigation on Treatment Results: Workers Compensation Patients Comparedwith Other Litigation Patients." Journal of Occupational Medicine. Vol. 31, No. 3:265-269, March, 1989.• http://www.slideshare.net/DiagnoseMyPain/effect-of-types-of-litigation-on-rtw
  24. 24. Outcome Studies• The www.MarylandClinicalDiagnostics.com methodsresulted in improved medical care and cost savings,ranging from $20,000 to $175,000 for various cases.Research from Johns Hopkins Hospital itself showed thatthe hospital achieved a 54% reduction in workerscompensation costs if they required that the injuredworkers limit their medical care to only Johns HopkinsHospital physicians. (27,28,29). Thus, these outcomestudies support the assertion that the use of thewww.MarylandClinicalDiagnostics.com tests improvemedical care and reduce health care costs.• 27) Stanton-Hicks, M., Baron, R.,Boas, R., Gordh, T., Harden,N., Hendler, N., Koltzenburg, M., Raj, P., Wilder,R.:"Complex Regional Pain Syndromes: Guidelines For Therapy." TheClinical Journal of Pain, Philadelphia,14: 155-166, 1998.• 28) Long, D, Davis, R, Speed, W, and Hendler, N, Fusion For Occult Post-Traumatic Cervical Facet Injury, Neurosurgery Quarterly, Vol. 16, No. 3,pp. 129-134, September,2006.• http://www.slideshare.net/DiagnoseMyPain/cervical-fusion-for-misdiagnosed-headache-and-whiplash• 29) Bernacki, E, and Tsai, S, Ten years experience using an integrated workers compensation management system to control workers compensation costs. J. of Occupationaland Environmental Medicine, 2003, 45:508-516• http://www.slideshare.net/DiagnoseMyPain/bernacki-j-occ-enviro-med•
  25. 25. Treatment Algorithm• Rank ordered test based on least invasive, leastexpensive testing, increasing in expense andcomplexity to most invasive, most expensive.• All testing selected as the result of “evidencebased medicine,” so there is a rationale forpicking a test.• Follows a diagnostic and treatment protocolwhich was proven to be effective, based on yearsof research with retrospective and prospectivestudies.
  26. 26. Bayesian versus Boolean Logic• Experience (Bayesian) versus binary thinking• Boolean logic is binary- “on-off,” or “yes-no”type of branching diagram. …In Boolean logic:• Each possibility gets an equal weight.• Is the tire flat? Yes-No• If flat, is there a leaky valve stem? Yes-No• If valve stem is not leaky, is there a cut sidewall? Yes-No.• If no cut, is there is a nail in the tire? yes-no• Repair the nail hole and drive away.
  27. 27. Bayesian Logic• In Bayesian logic:• Each outcome gets a weighted answer• Is the tire flat? Yes-No.• Have you has a flat in the past? –Yes-21 ofthem• Rank order the cause of previous flat tires.• 18 were due to a nail in the tire, 2 were due toa leaky valve stem, 1 was due to a cut sidewall.• Look first for the nail in the tire. Most likely.• Repair the nail puncture, and drive away
  28. 28. Ease of Use of Test versus Training• Training for medical students and residents isexpensive and time consuming• Many physicians in training, as well as those inpractice, have not been well schooled in how toobtain a thorough history• There is no chiropractic school nor medical schoolin the country which has a course specificallydesigned to teach about chronic pain.• The www.MarylandClinicalDiagnostics.com testscompensate for both of these deficits.
  29. 29. CPT Codes for billing for the test• Use the three following codes to reportservices for the Diagnostic Paradigm andTreatment Algorithm:• Use code 96102-52 –”psychological testing bytechnician” for technician time to set up test• Use code 96103 for “psychological testing by acomputer, “ for the period of time the patientspent taking the test• Use code 96101-52 for “psychological testing,interpretation and reporting by thepsychologist or physician”
  30. 30. Authors of Missed DiagnosesPapers, and Diagnostic Paradigm• Donlin Long, MD, Ph.D. former chairman of neurosurgery Johns HopkinsHospital, founder and Director of the Pain Clinic, Johns Hopkins Hospital,professor of neurosurgery, Johns Hopkins University School of Medicine• James Campbell, MD –professor of neurosurgery, Johns HopkinsUniversity School of Medicine, past president, American Pain Society• Reginald Davis, MD – former chief resident in neurosurgery, JohnsHopkins Hospital, assistant professor of neurosurgery, Johns HopkinsUniversity School of Medicine, chief of neurosurgery, Greater BaltimoreMedical Center• John Rybock, MD, assistant professor of neurosurgery Johns HopkinsUniversity School of Medicine, assistant dean for academic affairs, JohnsHopkins University School of Medicine.• Nelson Hendler, MD, MS, former assistant professor of neurosurgery-Johns Hopkins University School of Medicine, past president, AmericanAcademy of Pain Management• Lee Dellon, MD, PhD.-Professor of Surgery Johns Hopkins UniversitrySchool of Medicine• Mats Gronblad, MD, PhD-professor of physical medicine andrehabilitation medicine, Department of Physical Medicine andRehabilitation, Helsinki University Central Hospital, Helsinki, Finland
  31. 31. Contact Information• Nelson Hendler, MD, MS, CEO• Maryland Clinical Diagnostics• Former Assistant Professor of Neurosurgery• Johns Hopkins University School of Medicine• Past president -• American Academy of Pain Management• Phone 443-277-0306• Email DocNelse@aol.com• www.MarylandClinicalDiagnostics.com

×