Difficult diagnosis problem solving


The diagnostic eye

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Encompass factual foundation and the problem solving skill Data collection and manipulation skills as art of surgical pathology Can the art of surgical pathology be taught? Is diagnostic decision-making a semimystical combination of intuition and speculation that one gets after a period of exposure? A science with reductionist approach ? Both?


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In routine cases. Has seen similar cases many times before Apply the same solutions again Part of a well structured knowledge base accessed rapidly and efficiently. The typical situation”the prototype of the profession”in memory as stored chunks of information Combination of familiar stimuli after repeated exposure become recognisable as patterns . Apply the same when a new problem comes.high

Difficult case

Differential diagnostic considerations are obvious but not clearcut.  Distinctive features identified but pathologist have no personal exdperience of similar case and not aware of pertinent literature  The major educational goal-to master easily applied rules and  Move problems from the realm of complex decision making to realm of deterministic reasoning

Tools of diagnostic decision making

Diagnostic rules of the thumb  Data collection and valuation  Hypothesis manipulation skills,activation,evaluation,verification




LUCK,FLAIR,IMAGINATIVE INSIGHT  PETER MEDAWAR:”In surgical pathology,eligibility for diagnostic luck generally derives from years of effort to improve the application of the basic diagnostic tools.’”


Problemsolving and judgement heuristics out of thoughtful experience.  E= (e)3- f

Data collection

If there is A the diagnosis is B  Look for X in a why situation.  Then the finding (observation )on a glassslide become part of clinical problemsolving.

Mini tests

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Useful surgical pathology observations into minitests Successful data collection requires technical sensitivity(finding important things that are hard to find)& Technical specificity(ignoring look-alikes)& Precision(consistency in interpretation of identical findings) Combining other useful information(lab,clinical,radiological etc)

Variation in slide data collection skills

subtle clinically unsuspected Lacks1.clinicall y expected subtle .lacks 2.subtle when told present

Granuloma myometrium Granuloma liver in PBC Granuloma colon,when told it contains one


Hypothesis activation

Features visible when the expectation of their presence is established by a hypothesis  Grroved nuclei-if one thinks the possibility of an adult granulosa cell tumour  Corroborative information to build a case  Refutative information to negate a case  High value data for each.asign value or the probability of correctness to each

Statistical probability of correctness
Scale 0 –certain not to be correct  Scale 1. Certain to be correct


.very unlikely to be diagnostic  May be fitting in with an established diagnosis  If nothing is known of the patient,the prior probability of a target disease is simply the prevalence of the disease in the population.

How to diagnose

Clinical algorithm or mapping approach  Simultaneous assessment of multiple variables (pattern recognition approach)

Diagnosis is confirmed

When it is the simplest explanation for all the patient’s normal and abnormal findings.  Using diagnostic labels for prediction.


I have all the variables in hand.  Pt with lung cancer,positive metastatic mediastinal nodes ,bone and lung metastasis,-the survival prediction.  The future life of that individual patient

Simply put in risk category

Significant p value  But insignificant c value(clinical)  A 70 yr old man with focal welldifferentiated adenocarcinoma prostate.  No value for the prediction

Diagnostic improvement

Adequate information  Organised pattern of behaviour continually being refined by daily successes and failures  Informal programme of continuous diagnostic improvement from experience(called quality products),the label that best serves the needs of patients.  Permanent division of cases into ,1.those I can diagnose repeatedly with deterministic techniques,2.the cases that someone else has to tell me the answer to.

Hypothesis activation

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I never thought of that diagnosis I never saw that subtle finding I didn’t know to link that finding with the hypothesis To overcome this,for proper hypothesis activation we need skills of creativity/intuition Medawar”encourage this by acquiring the habit of reflection”

Hypothesis evaluation to reduce diagnostic errors

25 yr old woman with breast mass.low clinical probability of malignancy.but needle biopsy show overt malignant features.A tendency for low anchoring (lack of flexibility to believe in new data.)extreme low anchoring “I have never seen that in my practice of 20 years”avoidance of rare diagnosis.

Zebra hunting

Give high probability to rare events and hunt for it.  Eg:a few lymphocytes in the epidermis(in dermatitis)tries to establish it as cutaneous lymphoma  Effort and money wasted before the diagnosis is proved to be incorrect(lymph node biopsy,immunohistochemistry etc)

Surgical pathology diagnosis

A respected subspeciality of clinical medicine.  Evidence-based medicine using IHC  Has a scientific basis and acceptably low levels of diagnostic variations can occur.  Traditionally the speciality has attempted to tap the best diagnosticians for educational leadership roles

Much to be learned from the decisionmaking of

1.the greats  2the naturals  3.the lucky ones who always get it right  4.also from those who always get it wrong.

Thank you!!!!

Medicine is a noble profession for those who are noble.(Osler)  The philosopher begins with medicine and the physician ends with philosophy(Aristotle)